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Alkabie S, Diamond EL. Erdheim-Chester Disease Masquerading as CLIPPERS. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2024; 11:e200294. [PMID: 39047207 PMCID: PMC11270893 DOI: 10.1212/nxi.0000000000200294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 06/12/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVES To present 4 patients with Erdheim-Chester disease (ECD) based on clinical, radiologic, histopathologic, and molecular genetic findings who had enhancing brainstem lesions and were initially believed to have chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). METHODS Case series. RESULTS Although patients with ECD can demonstrate clinical and imaging features similar to CLIPPERS, refractoriness to corticosteroids, lack of fulfillment of specific MRI criteria (i.e., enhancing lesions >3 mm, T2 abnormalities that exceed areas of T1 postgadolinium enhancement), and systemic findings such as "hairy kidney" appearance and metadiaphyseal osteosclerosis on 18F-fluorodeoxyglucose PET-CT help discriminate it from CLIPPERS. DISCUSSION ECD is a histiocytic neoplasm characterized by multiorgan infiltration of clonal histiocytes carrying activating variants of the MAPK-ERK pathway. Neurologic involvement occurs in up to 40% of ECD with frequent brainstem lesions that can mimic acquired neuroinflammatory disorders, such as CLIPPERS. ECD is an important CLIPPERS mimic with distinct pathophysiology and targeted treatments. We highlight the need to consider histiocytic disorders among other alternate diagnoses when findings are not classic for CLIPPERS.
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Affiliation(s)
- Samir Alkabie
- From the Department of Neurology (S.A.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital; and Department of Neurology (E.L.D.), Memorial Sloan Kettering Cancer Center, New York
| | - Eli L Diamond
- From the Department of Neurology (S.A.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital; and Department of Neurology (E.L.D.), Memorial Sloan Kettering Cancer Center, New York
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2
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Cruciani A, Motolese F, Tortorella C, Haggiag S, Santoro F, Pozzilli V, Rossi M, Pilato F, Gasperini C, Di Lazzaro V, Capone F. Unusual CLIPPERS presentation with a predominant spinal cord involvement: case report and review of the literature. Neurol Sci 2024; 45:3737-3742. [PMID: 38499887 DOI: 10.1007/s10072-024-07469-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/13/2024] [Indexed: 03/20/2024]
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a discrete nosological entity characterized by punctate and curvilinear gadolinium enhancement "peppering" the pons and a strong response to steroids. MRI images typically show pontine and cerebellar punctate-enhancing lesions, which occasionally spread up to the juxtacortical areas and down to the spinal cord. Interestingly, the more distant the lesion is from the pons, the less intense they become. Herein, we describe an extremely rare case of CLIPPERS presenting with predominant spinal cord involvement; then, we searched in the literature the available cases with a similar presentation. Our case focuses attention on a rare MRI CLIPPERS presentation. Since CLIPPERS has a dramatic response to corticosteroid treatment, it is fundamental to promptly recognize its MRI pattern to start treatment as soon as possible.
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Affiliation(s)
- Alessandro Cruciani
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy.
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
| | - Francesco Motolese
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Carla Tortorella
- Dipartimento di Neuroscienze, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Shalom Haggiag
- Dipartimento di Neuroscienze, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Francesca Santoro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Valeria Pozzilli
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Mariagrazia Rossi
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fabio Pilato
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Claudio Gasperini
- Dipartimento di Neuroscienze, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fioravante Capone
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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3
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McEntire CRS, Glenn T, Unizony S, Cho T, Reda H, Chwalisz BK. Symmetric leukoencephalopathy associated with systemic lupus erythematosus: A systematic review of a distinctive neurorheumatologic syndrome. Mult Scler Relat Disord 2024; 88:105717. [PMID: 38943754 DOI: 10.1016/j.msard.2024.105717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 06/04/2024] [Accepted: 06/08/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND A symmetric leukoencephalopathy can occur in the context of systemic lupus erythematosus (SLE), often as a first manifestation of underlying rheumatologic disease. Recognition of this distinctive syndrome can prompt investigation for SLE when undiagnosed, or prompt treatment initiation when the diagnosis is already known. Earlier recognition of this syndrome could lead to more effective treatment of the disease. METHODS Clinical, laboratory, and radiographic features of three patients were described from an academic medical center in the United States with treatment dates between 2015 and 2022. A systematic review of literature from 1991 to 2023 yielded data for an additional 23 patients. RESULTS Twenty-six total patients with symmetric leukoencephalopathy were included in this study. The median age of the patients was 37 years (range 10-69), 22 patients (85 %) were female, and 4 (15 %) were male. Fourteen of 26 patients (54 %) had this as the first clinical manifestation of SLE. Contrast enhancement was present on MRI brain in 3/26 (88 %) patients. Twenty patients (77 %) were treated with pulse-dose steroids, and all but one patient received some immunomodulatory therapy. Seven patients (27 %) progressed to death. No meaningful predictive differences were found between patients who survived and those who did not. CONCLUSIONS In this case series and literature review patients developed symmetric leukoencephalopathy in systemic lupus erythematosus most often as the first clinical manifestation of SLE. Clinicians should consider this syndrome in any patient with acute onset of symmetric leukoencephalopathy on brain magnetic resonance imaging.
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Affiliation(s)
- Caleb R S McEntire
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States.
| | - Trevor Glenn
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States
| | - Sebastian Unizony
- Rheumatology, Allergy and Immunology Division, Massachusetts General Hospital, Boston, MA, United States
| | - Tracey Cho
- Neuro-Immunology Division, University of Iowa Hospitals and Clinics, United States
| | - Haatem Reda
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Bart K Chwalisz
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
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4
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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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5
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Lemarchant B, de Saint Basile G, Zephir H, Roelens M, Dubois R, Boucher J, Taieb G. Familial hemophagocytic lymphohistiocytosis: from macrophage activation syndrome to CLIPPERS. J Neurol 2024; 271:2893-2897. [PMID: 38383762 DOI: 10.1007/s00415-024-12241-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Bruno Lemarchant
- Department of Neurology, Unité de Neurologie Inflammatoire, CRC-SEP, CHU Lille, Hôpital Roger Salengro, Lille, France.
| | - Geneviève de Saint Basile
- Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children-Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Hélène Zephir
- Department of Neurology, Unité de Neurologie Inflammatoire, CRC-SEP, CHU Lille, Hôpital Roger Salengro, Lille, France
| | - Marie Roelens
- Study Center for Primary Immunodeficiencies, Necker Hospital for Sick Children-Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Julie Boucher
- Department of Neurology, CH Boulogne Sur Mer, Hôpital Duchenne, Boulogne-sur-Mer, France
| | - Guillaume Taieb
- Department of Neurology, CHU Montpellier, Hôpital Gui de Chauliac, Montpellier, France.
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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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7
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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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8
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Shervedani AK, Tabibian F, Khotbesara MG, Adibi I. Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids triggered by Hodgkin's lymphoma: A case report and brief literature review. Clin Case Rep 2024; 12:e8377. [PMID: 38161651 PMCID: PMC10753635 DOI: 10.1002/ccr3.8377] [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: 09/05/2023] [Revised: 11/27/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024] Open
Abstract
Key Clinical Message We presented a patient, diagnosed with lymphoma-associated CLIPPERS, 11 years after lymphoma treatment. Therefore, CLIPPERS may be paraneoplastic neurological syndrome of lymphoma, which needs to be considered in the follow-up of lymphoma cases. Abstract Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare central nervous system disorder with a recent increase in incidence. There are few reports of lymphoma-associated CLIPPERS, although the relationship between these two diseases and the pathophysiology of CLIPPERS in general need further investigation. Here, we present a patient with a history of Hodgkin's lymphoma (HL) more than 10 years before the onset of CLIPPERS, in contrast to the majority of previously reported lymphoma-associated cases, and discuss the possibility that CLIPPERS is the paraneoplastic neurological syndrome of HL. This highlights the need to consider CLIPPERS as a differential diagnosis during follow-up of patients with a history of lymphoma.
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Affiliation(s)
| | - Farinaz Tabibian
- Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
| | | | - Iman Adibi
- Neurosciences Research CenterIsfahan University of Medical SciencesIsfahanIran
- Department of NeurologyIsfahan University of Medical SciencesIsfahanIran
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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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Roy S, Barreras P, Pardo CA, Graves JS, Zamvil SS, Newsome SD. Relapsing Encephalomyelitis After COVID-19 Infection and Vaccination: From the National MS Society Case Conference Proceedings. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/3/e200112. [PMID: 37015826 PMCID: PMC10074377 DOI: 10.1212/nxi.0000000000200112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/09/2023] [Indexed: 04/06/2023]
Abstract
Prior case studies suggest that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its vaccines may unmask CNS neuroinflammatory conditions. We present a case of relapsing steroid-responsive encephalomyelitis after SARS-CoV-2 infection and subsequent COVID-19 vaccination. We also characterize the frequency of CNS neuroinflammatory events reported in the literature after both SARS-CoV-2 infection and COVID-19 vaccination.
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Affiliation(s)
- Shuvro Roy
- From the Department of Neurology (S.R., P.B., C.A.P., S.D.N.), Johns Hopkins School of Medicine; Department of Neurology (J.S.G.), University of California San Diego School of Medicine; and Department of Neurology (S.S.Z.), University of California San Francisco School of Medicine
| | - Paula Barreras
- From the Department of Neurology (S.R., P.B., C.A.P., S.D.N.), Johns Hopkins School of Medicine; Department of Neurology (J.S.G.), University of California San Diego School of Medicine; and Department of Neurology (S.S.Z.), University of California San Francisco School of Medicine
| | - Carlos A Pardo
- From the Department of Neurology (S.R., P.B., C.A.P., S.D.N.), Johns Hopkins School of Medicine; Department of Neurology (J.S.G.), University of California San Diego School of Medicine; and Department of Neurology (S.S.Z.), University of California San Francisco School of Medicine
| | - Jennifer S Graves
- From the Department of Neurology (S.R., P.B., C.A.P., S.D.N.), Johns Hopkins School of Medicine; Department of Neurology (J.S.G.), University of California San Diego School of Medicine; and Department of Neurology (S.S.Z.), University of California San Francisco School of Medicine
| | - Scott S Zamvil
- From the Department of Neurology (S.R., P.B., C.A.P., S.D.N.), Johns Hopkins School of Medicine; Department of Neurology (J.S.G.), University of California San Diego School of Medicine; and Department of Neurology (S.S.Z.), University of California San Francisco School of Medicine
| | - Scott D Newsome
- From the Department of Neurology (S.R., P.B., C.A.P., S.D.N.), Johns Hopkins School of Medicine; Department of Neurology (J.S.G.), University of California San Diego School of Medicine; and Department of Neurology (S.S.Z.), University of California San Francisco School of Medicine.
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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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12
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Saénz-Silva J, Ordinola Navarro A. CLIPPERS Syndrome After Vaccination. An Unusual ASIA Presentation. REUMATOLOGIA CLINICA 2023; 19:168-170. [PMID: 36906391 DOI: 10.1016/j.reumae.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/19/2021] [Indexed: 03/11/2023]
Abstract
The chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) and autoimmune/inflammatory syndrome induced by adjuvants (ASIA) were described a decade ago. There are a limited number of reports and these diseases are still underdiagnosed. We presented a 35 years-old patient with clinical manifestations of cerebellum affection and enhancement in the MRI, with the influenza vaccine as the only triggering factor. Infectious diseases, malignancy, and additional systemic involvement were ruled out; therefore, on suspicion of CLIPPERS syndrome, the patient received corticosteroid therapy with an adequate response. The knowledge of CLIPPERS syndrome as an unusual ASIA presentation and high response to the corticosteroids may lead to a timely diagnosis, appropriate treatment, and follow up with better outcomes for patients.
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Affiliation(s)
- Juan Saénz-Silva
- Department of Neurology, Hospital de Especialidades «Dr. Antonio Fraga Mouret»,Centro Médico Nacional La Raza del Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Alberto Ordinola Navarro
- Department of Internal medicine, Hospital de Especialidades «Dr. Antonio Fraga Mouret», Centro Médico Nacional La Raza del Instituto Mexicano del Seguro Social, Mexico City, Mexico.
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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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14
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Leboyan A, Esselin F, Bascou AL, Duflos C, Ion I, Charif M, Castelnovo G, Carra-Dalliere C, Ayrignac X, Kerschen P, Chbicheb M, Nguyen L, Maria ATJ, Guilpain P, Carriere M, de Champfleur NM, Vincent T, Jentzer A, Labauge P, Devaux JJ, Taieb G. Immune-mediated diseases involving central and peripheral nervous systems. Eur J Neurol 2023; 30:490-500. [PMID: 36366904 DOI: 10.1111/ene.15628] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/03/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND PURPOSE In addition to combined central and peripheral demyelination, other immune diseases could involve both the central nervous system (CNS) and peripheral nervous system (PNS). METHODS To identify immune-mediated diseases responsible for symptomatic combined central/peripheral nervous system involvement (ICCPs), we conducted a multicentric retrospective study and assessed clinical, electrophysiological, and radiological features of patients fulfilling our ICCP criteria. RESULTS Thirty patients (20 males) were included and followed during a median of 79.5 months (interquartile range [IQR] = 43-145). The median age at onset was 51.5 years (IQR = 39-58). Patients were assigned to one of four groups: (i) monophasic disease with concomitant CNS/PNS involvement including anti-GQ1b syndrome (acute polyradiculoneuropathy + rhombencephalitis, n = 2), checkpoint inhibitor-related toxicities (acute polyradiculoneuropathy + encephalitis, n = 3), and anti-glial fibrillary acidic protein astrocytopathy (subacute polyradiculoneuropathy and meningoencephalomyelitis with linear gadolinium enhancements, n = 2); (ii) chronic course with concomitant CNS/PNS involvement including paraneoplastic syndromes (ganglionopathy/peripheral hyperexcitability + limbic encephalitis, n = 4); (iii) chronic course with sequential CNS/PNS involvement including POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) syndrome (polyradiculoneuropathy + strokes, n = 2), histiocytosis (polyradiculoneuropathy + lepto-/pachymeningitis, n = 1), and systemic vasculitis (multineuropathy + CNS vasculitis/pachymeningitis, n = 2); and (iv) chronic course with concomitant or sequential CNS/PNS involvement including combined central and peripheral demyelination (polyradiculoneuropathy + CNS demyelinating lesions, n = 10) and connective tissue diseases (ganglionopathy/radiculopathy/multineuropathy + limbic encephalitis/transverse myelitis/stroke, n = 4). CONCLUSIONS We diagnosed nine ICCPs. The timing of central and peripheral manifestations and the disease course help determine the underlying immune disease. When antibody against neuroglial antigen is identified, CNS and PNS involvement is systematically concomitant, suggesting a common CNS/PNS antigen and a simultaneous disruption of blood-nerve and blood-brain barriers.
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Affiliation(s)
- Aurelie Leboyan
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Florence Esselin
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Anne-Laure Bascou
- Clinical Research and Epidemiology Unit, University Hospital Center, University of Montpellier, Montpellier, France
| | - Claire Duflos
- Clinical Research and Epidemiology Unit, University Hospital Center, University of Montpellier, Montpellier, France
| | - Ioana Ion
- Department of Neurology, Caremeau University Hospital Center, Nîmes, France
| | - Mahmoud Charif
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | | | | | - Xavier Ayrignac
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Philippe Kerschen
- Department of Neurology, Luxembourg Hospital Center, Luxembourg City, Luxembourg
| | - Mohamed Chbicheb
- Department of Neurology, Narbonne Hospital Center, Narbonne, France
| | - Ludovic Nguyen
- Department of Neurology, Perpignan Hospital Center, Perpignan, France
| | - Alexandre T J Maria
- Department of Internal Medicine, Saint Eloi University Hospital Center, Montpellier, France
| | - Philippe Guilpain
- Department of Internal Medicine, Saint Eloi University Hospital Center, Montpellier, France
| | - Mathilde Carriere
- Department of Neuroradiology, Gui de Chauliac University Hospital Center, Montpellier, France
| | | | - Thierry Vincent
- Department of Immunology, Saint Eloi University Hospital Center, Montpellier, France
| | - Alexandre Jentzer
- Department of Immunology, Saint Eloi University Hospital Center, Montpellier, France
| | - Pierre Labauge
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
| | - Jérôme J Devaux
- Institute of Functional Genomics, National Center for Scientific Research UMR5203, Montpellier, France
| | - Guillaume Taieb
- Department of Neurology, Gui de Chauliac University Hospital Center, Montpellier, France
- Institute of Functional Genomics, National Center for Scientific Research UMR5203, Montpellier, France
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15
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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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16
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Ayrignac X, Carra-Dallière C, Marelli C, Taïeb G, Labauge P. Adult-Onset Genetic Central Nervous System Disorders Masquerading as Acquired Neuroinflammatory Disorders: A Review. JAMA Neurol 2022; 79:1069-1078. [PMID: 35969413 DOI: 10.1001/jamaneurol.2022.2141] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Adult-onset genetic disorders may present with clinical and magnetic resonance imaging (MRI) features suggestive of acquired inflammatory diseases. An ever-growing number of potentially treatable adult-onset genetic neuroinflammatory disorders have been described in the past few years that need to be rapidly identified. Observations Adult-onset acquired neuroinflammatory disorders encompass a large group of central nervous system (CNS) diseases with varying presentation, MRI characteristics, and course, among which the most common is multiple sclerosis. Despite recent progress, including the discovery of specific autoantibodies, a significant number of adult-onset neuroinflammatory disorders with progressive or relapsing course still remain without a definite diagnosis. In addition, some patients with genetic disorders such as leukodystrophies, hemophagocytic lymphohistiocytosis, or genetic vasculopathies can mimic acquired neuroinflammatory disorders. These genetic disorders, initially described in pediatric populations, are increasingly detected in adulthood thanks to recent progress in molecular genetics and the larger availability of high-throughput sequencing technologies. Conclusions and Relevance Genetic adult-onset neuroinflammatory diseases are at the border between primary CNS inflammatory diseases and systemic disorders with multiorgan involvement and predominantly neurologic manifestations. Neurologists must be aware of the main clues and red flags so they can confirm a diagnosis early, when some of these genetic disorders can be successfully treated.
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Affiliation(s)
- Xavier Ayrignac
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France.,Department of Neurology, Montpellier University Hospital, Montpellier, France.,Reference Centre for Adult-Onset Leukoencephalopathy and Leukodystrophies, Montpellier University Hospital, Montpellier, France.,Reference Centre for Multiple Sclerosis, Montpellier University Hospital, Montpellier, France
| | - Clarisse Carra-Dallière
- Department of Neurology, Montpellier University Hospital, Montpellier, France.,Reference Centre for Adult-Onset Leukoencephalopathy and Leukodystrophies, Montpellier University Hospital, Montpellier, France.,Reference Centre for Multiple Sclerosis, Montpellier University Hospital, Montpellier, France
| | - Cecilia Marelli
- Department of Neurology, Montpellier University Hospital, Montpellier, France.,Molecular Mechanisms in Neurodegenerative Dementias, University of Montpellier, École Pratique des Hautes Études, INSERM, Montpellier, France.,Expert Centre for Neurogenetic Diseases and Adult Mitochondrial and Metabolic Diseases, Montpellier University Hospital, Montpellier, France
| | - Guillaume Taïeb
- Department of Neurology, Montpellier University Hospital, Montpellier, France
| | - Pierre Labauge
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France.,Department of Neurology, Montpellier University Hospital, Montpellier, France.,Reference Centre for Adult-Onset Leukoencephalopathy and Leukodystrophies, Montpellier University Hospital, Montpellier, France.,Reference Centre for Multiple Sclerosis, Montpellier University Hospital, Montpellier, France
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Pathomechanisms in demyelination and astrocytopathy: autoantibodies to AQP4, MOG, GFAP, GRP78 and beyond. Curr Opin Neurol 2022; 35:427-435. [PMID: 35674086 DOI: 10.1097/wco.0000000000001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the recently emerging pathomechanisms of diseases associated with autoantibodies to AQP4, MOG, GFAP, GRP78 and further novel targets. We discuss novel biomarkers and therapeutic approaches. RECENT FINDINGS Although complement-mediated cytotoxicity (CDC) is regarded as the major effector mechanism for AQP4-IgG in neuromyelitis optica spectrum disorders (NMOSD), recent studies helped to understand the relevance of complement-independent effector mechanisms. For MOG-IgG mediated diseases the role of CDC is less clear. MOG-IgG may trigger a tightly controlled FcR and BTK-driven microglia proliferative response in MOG-antibody-associated diseases. Differences of antibody-mediated tissue damage may reflect differential response to therapy. In addition, antibodies to GFAP, GRP78 and further novel targets have been implicated in demyelination and astrocytopathy. SUMMARY Elucidating the whole spectrum of effector functions in diseases mediated by AQP4-IgG and MOG-IgG and understanding the role of additional novel autoantibodies involved in demyelination and astrocytopathy may guide further novel treatment decisions.
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18
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Guo J, Bu Y, Liu W. Case Report: A Case With MOGAD and Anti-NMDAR Encephalitis Overlapping Syndrome Mimicing Radiological Characteristics of CLIPPERS. Front Immunol 2022; 13:832084. [PMID: 35493443 PMCID: PMC9047684 DOI: 10.3389/fimmu.2022.832084] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Herein, we reported a case of a young man diagnosed with MNOS (anti-myelin oligodendrocyte glycoprotein associated disease (MOGAD) and anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis overlapping syndrome, i.e., MNOS), whose imaging findings in magnetic resonance imaging (MRI) mimicked chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). We reported a case of refractory anti-NMDAR encephalitis that recurred after standard first-line and second-line treatment. The patient presented with CLIPPERS on imaging at recent hospital admission, and his MOG antibodies were seropositive. After intravenous methylprednisolone (IVMP) treatment, the patient’s symptoms were significantly alleviated. In this case, we demonstrated that MNOS could mimic the radiological characteristics of CLIPPERS. Future studies should focus on the diagnosis and treatment of antibody overlap syndrome.
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19
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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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20
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Lee VWM, Khoo TB, Daud CZBC, Latif KBA. Pediatric-Onset CLIPPERS: A Case Report and Literature Review. ANNALS OF CHILD NEUROLOGY 2022. [DOI: 10.26815/acn.2022.00017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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21
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Galazky I, Büntjen L, Voges J, Sandalcioglu IE, Mawrin C, Haghikia A. Brain biopsy in patients with CLIPPERS syndrome: why and when. Ther Adv Neurol Disord 2022; 15:17562864211062821. [PMID: 35126669 PMCID: PMC8808022 DOI: 10.1177/17562864211062821] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is an inflammatory disorder of the central nervous system (CNS), predominantly involving the brainstem with a characteristic magnetic resonance imaging (MRI) appearance and clinical and radiological responsiveness to glucocorticosteroids. Yet diagnostic biomarkers are missing and other immune-mediated, (para-) infectious and malignant causes mimic CLIPPERS-like MRI presentations. We report the case of a 51-year-old male patient with CLIPPERS who repeatedly responded well to high-dose corticosteroids. After 7 months, however, treatment failed, and he had a biopsy-confirmed diagnosis of a CNS B-cell lymphoma. Clinical and MRI signs of CLIPPERS include a wide spectrum of differential diagnoses which often arise only later during the course of disease. Similar to the case presented here, delayed diagnosis and specific therapy may contribute to an unfavorable outcome. Hence, we propose that in the absence of other diagnostic markers, brain biopsy should be performed as early as possible in CLIPPERS patients.
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Affiliation(s)
- Imke Galazky
- Department of Neurology, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
| | - Lars Büntjen
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Jürgen Voges
- Department of Stereotactic Neurosurgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- German Center for Neurodegenerative Disease (DZNE), Bonn, Germany
| | - I. Erol Sandalcioglu
- Department of Neurosurgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christian Mawrin
- Institute of Neuropathology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Aiden Haghikia
- Department of Neurology, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
- German Center for Neurodegenerative Disease (DZNE), Bonn, Germany
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22
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Doubrovinskaia S, Sahm F, Thier MC, Bendszus M, Wick W, Seliger C, Kaulen LD. Primary CNS lymphoma after CLIPPERS: a case series. J Neurol Neurosurg Psychiatry 2021; 92:1348-1349. [PMID: 33789924 DOI: 10.1136/jnnp-2020-325759] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/25/2021] [Accepted: 02/16/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Sofia Doubrovinskaia
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Felix Sahm
- Department of Neuropathology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany.,Clinical Cooperation Unit Neuropathology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Baden-Württemberg, Germany
| | - Marc Christian Thier
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Wolfgang Wick
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany.,Clinical Cooperation Unit Neuro-Oncology, German Consortium for Translational Cancer Research (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Baden-Württemberg, Germany
| | - Corinna Seliger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Leon D Kaulen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
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Abstract
Meningitis and encephalitis are inflammatory syndromes of the meninges and brain parenchyma, respectively, and may be identified either by finding definitive evidence of inflammation on tissue pathology or by cerebrocpinal fluid (CSF) analysis showing pleocytosis or intrathecal antibody synthesis. Clinicians evaluating undifferentiated meningitis or encephalitis should simultaneously consider autoimmune, infectious, and neoplastic causes, using patient risk factors, clinical syndrome, and diagnostic results including CSF and MRI findings to narrow the differential diagnosis. If an autoimmune cause is favored, an important early diagnostic question is whether a specific neural autoantibody is likely to be identified.
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Affiliation(s)
- Megan B Richie
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
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Dumonceau AG, Ameli R, Rogemond V, Ruiz A, Joubert B, Muñiz-Castrillo S, Vogrig A, Picard G, Ambati A, Benaiteau M, Rulquin F, Ciron J, Deiva K, de Broucker T, Kremer L, Kerschen P, Sellal F, Bouldoires B, Genet R, Biberon J, Bigot A, Duval F, Issa N, Rusu EC, Goudot M, Dutray A, Devoize JL, Hopes L, Kaminsky AL, Philbert M, Chanson E, Leblanc A, Morvan E, Andriuta D, Diraison P, Mirebeau G, Derollez C, Bourg V, Bodard Q, Fort C, Grigorashvili-Coin I, Rieul G, Molinier-Tiganas D, Bonnan M, Tchoumi T, Honnorat J, Marignier R. Glial Fibrillary Acidic Protein Autoimmunity: A French Cohort Study. Neurology 2021; 98:e653-e668. [PMID: 34799461 PMCID: PMC8829963 DOI: 10.1212/wnl.0000000000013087] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 11/12/2021] [Indexed: 11/21/2022] Open
Abstract
Background and Objectives To report the clinical, biological, and imaging features and clinical course of a French cohort of patients with glial fibrillary acidic protein (GFAP) autoantibodies. Methods We retrospectively included all patients who tested positive for GFAP antibodies in the CSF by immunohistochemistry and confirmed by cell-based assay using cells expressing human GFAPα since 2017 from 2 French referral centers. Results We identified 46 patients with GFAP antibodies. Median age at onset was 43 years, and 65% were men. Infectious prodromal symptoms were found in 82%. Other autoimmune diseases were found in 22% of patients, and coexisting neural autoantibodies in 11%. Tumors were present in 24%, and T-cell dysfunction in 23%. The most frequent presentation was subacute meningoencephalitis (85%), with cerebellar dysfunction in 57% of cases. Other clinical presentations included myelitis (30%) and visual (35%) and peripheral nervous system involvement (24%). MRI showed perivascular radial enhancement in 32%, periventricular T2 hyperintensity in 41%, brainstem involvement in 31%, leptomeningeal enhancement in 26%, and reversible splenial lesions in 4 cases. A total of 33 of 40 patients had a monophasic course, associated with a good outcome at last follow-up (Rankin Score ≤2: 89%), despite a severe clinical presentation. Adult and pediatric features are similar. Thirty-two patients were treated with immunotherapy. A total of 11/22 patients showed negative conversion of GFAP antibodies. Discussion GFAP autoimmunity is mainly associated with acute/subacute meningoencephalomyelitis with prodromal symptoms, for which tumors and T-cell dysfunction are frequent triggers. The majority of patients followed a monophasic course with a good outcome.
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Affiliation(s)
- Alice Gravier Dumonceau
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France
| | - Roxana Ameli
- Service d'imagerie médicale, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France
| | - Veronique Rogemond
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Anne Ruiz
- Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR5292, 69003 Lyon, France
| | - Bastien Joubert
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Sergio Muñiz-Castrillo
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Alberto Vogrig
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Geraldine Picard
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Aditya Ambati
- Stanford University Center for Sleep Sciences and Medecine, Palo Alto, CA, USA
| | - Marie Benaiteau
- Service de neurologie cognitive, épilepsie, sommeil et mouvements anormaux, Hôpital Pierre-Paul Riquet, Hôpitaux de Toulouse, 31059 Toulouse, France
| | - Florence Rulquin
- Service de neurologie inflammatoire et neuro-oncologie, Hôpital Pierre-Paul Riquet, Hôpitaux de Toulouse, 31059 Toulouse, France
| | - Jonathan Ciron
- Service de neurologie inflammatoire et neuro-oncologie, Hôpital Pierre-Paul Riquet, Hôpitaux de Toulouse, 31059 Toulouse, France
| | - Kumaran Deiva
- Service de neuropédiatrie, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, 94270 Le Kremlin-Bicêtre, France
| | - Thomas de Broucker
- Service de neurologie, Hôpital Delafontaine, Centre Hospitalier de Saint-Denis, 93205 Saint-Denis, France
| | - Laurent Kremer
- Service de neurologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 67200 Strasbourg, France
| | - Philippe Kerschen
- Service de neurologie, Centre Hospitalier de Luxembourg, 1210 Luxembourg, Luxembourg
| | - François Sellal
- Service de neurologie, Hôpitaux Civils de Colmar, 68000 Colmar, France ; Unité INSERM U-1118, Faculté de Médecine, Université de Strasbourg
| | - Bastien Bouldoires
- Service de médecine interne, Hôpitaux civils de Colmar, 68000 Colmar, France
| | - Roxana Genet
- Service de médecine interne, Hôpital d'Instruction des Armées Legouest, 57000 Metz, France
| | - Jonathan Biberon
- Service de neurologie, Centre Hospitalier Régional Universitaire de Tours, 37044 Tours, France
| | - Adrien Bigot
- Service de médecine interne et immunologie clinique, Centre Hospitalier Régional Universitaire de Tours, 37044 Tours, France
| | - Fanny Duval
- Service de neurologie et maladies neuromusculaires, Groupe Hospitalier Pellegrin, Hôpitaux de Bordeaux, 33000 Bordeaux, France
| | - Nahema Issa
- Service de médecine intensive et réanimation, Hôpital Saint André, 33000 Bordeaux, France
| | - Elena-Camelia Rusu
- Service de neurologie, Hôpital Sainte Musse, Centre Hospitalier Intercommunal de Toulon, 83056 Toulon, France
| | - Mathilde Goudot
- Service de neurologie, Hôpital Emile Muller, 68100 Mulhouse, France
| | - Anais Dutray
- Service de neurologie, Centre Hospitalier de Perpignan, 66046 Perpignan, France
| | - Jean Louis Devoize
- Pôle Cardio-vasculaire et métabolique, Centre hospitalier de Cayenne, 97300 Cayenne, France
| | - Lucie Hopes
- Service de neurologie, Hôpital Central, CHRU Nancy, 54035 Nancy, France
| | - Anne-Laure Kaminsky
- Service de neurologie, CHU de Saint-Etienne, 42270 Saint-Priest-en-Jarez, France
| | - Marion Philbert
- Service de neuropédiatrie, Site Mère Enfant, CHU Martinique, 97200 Fort-de-France, France
| | - Eve Chanson
- Service de neurologie, CHU Gabriel-Montpied, CHU de Clermont-Ferrand, 63003 Clermont-Ferrand, France
| | - Amelie Leblanc
- Service de neurologie, Hôpital d'Instruction des Armées Clermont-Tonnerre, 29240 Brest, France
| | - Erwan Morvan
- Service de neurologie, Hôpital Fondation Adolphe de Rothschild, 75019 Paris, France
| | - Daniela Andriuta
- Service de Neurologie et Laboratoire de Neurosciences Fonctionnelles et Pathologies, Centre Hospitalier universitaire d'Amiens et Université de Picardie Jules Verne, Amiens, France
| | - Philippe Diraison
- Service de neurologie, Hôpital Laënnec, Centre Hospitalier de Cornouaille, 29107 Quimper, France
| | - Gabriel Mirebeau
- Service de neurologie, Centre Hospitalier Universitaire de La Réunion, 97410 Saint Pierre, France
| | - Celine Derollez
- Service de neurologie, Hôpital Roger Salengro, Centre Hospitalier Universitaire de Lille, 59037 Lille, France
| | - Veronique Bourg
- Service de neurologie, Hôpital Pasteur 2, Centre Hospitalier Universitaire de Nice, 06000 Nice, France
| | - Quentin Bodard
- Service de médecine interne et maladies infectieuses, Centre Hospitalier d'Angoulême, 16959 Angoulême, France
| | - Clementine Fort
- Service de neurologie pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 69677 Lyon/Bron, France
| | | | - Guillaume Rieul
- Service de réanimation, Centre Hospitalier de Saint-Brieuc, 22027 Saint-Brieuc, France
| | - Daniela Molinier-Tiganas
- Service de médecine polyvalente et de médecine interne, Centre Hospitalier Le Mans, 72037 Le Mans, France
| | - Mickaël Bonnan
- Service de neurologie, Centre Hospitalier de Pau, 64046 Pau, France
| | - Thierry Tchoumi
- Service de neurologie/UNV, Centre Hospitalier de Saintonge, 17100 Saintes, France
| | - Jérôme Honnorat
- Centre de référence des syndromes neurologiques paranéoplasiques et encéphalites auto-immunes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France ; Institut NeuroMyoGène, INSERM 1217 et CNRS UMR5310, 69008 Lyon, France ; Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, 69008 Lyon, France
| | - Romain Marignier
- Service de neurologie, sclérose en plaques, pathologies de la myéline et neuro-inflammation, and Centre de Référence des Maladies Inflammatoires Rares du Cerveau et de la Moelle, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, 69677 Lyon/Bron, France.,Centre de Recherche en Neurosciences de Lyon, INSERM 1028 et CNRS UMR5292, 69003 Lyon, France
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Malik P, Antonini L, Mannam P, Aboobacker FN, Merve A, Gilmour K, Rao K, Kumar S, Mani SE, Eleftheriou D, Rao A, Hemingway C, Sudhakar SV, Bartram J, Mankad K. MRI Patterns in Pediatric CNS Hemophagocytic Lymphohistiocytosis. AJNR Am J Neuroradiol 2021; 42:2077-2085. [PMID: 34620587 DOI: 10.3174/ajnr.a7292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/19/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Neuroimaging has an important role in detecting CNS involvement in children with systemic or CNS isolated hemophagocytic lymphohistiocytosis. We characterized a cohort of pediatric patients with CNS hemophagocytic lymphohistiocytosis focusing on neuroradiologic features and assessed whether distinct MR imaging patterns and genotype correlations can be recognized. MATERIALS AND METHODS We retrospectively enrolled consecutive pediatric patients diagnosed with hemophagocytic lymphohistiocytosis with CNS involvement treated at 2 pediatric neurology centers between 2010 and 2018. Clinical and MR imaging data were analyzed. RESULTS Fifty-seven children (40 primary, 70%) with a median age of 36 months (interquartile range, 5.5-80.8 months) were included. One hundred twenty-three MR imaging studies were assessed, and 2 broad imaging patterns were identified. Pattern 1 (significant parenchymal disease, 32/57, 56%) was seen in older children (P = .004) with worse clinical profiles. It had 3 onset subpatterns: multifocal white matter lesions (21/32, 66%), brainstem predominant disease (5, 15%), and cerebellitis (6, 19%). All patients with the brainstem pattern failed to meet the radiologic criteria for chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids. An attenuated imaging phenotype (pattern 2) was seen in 25 patients (44%, 30 studies) and was associated with younger age. CONCLUSIONS Distinct MR imaging patterns correlating with clinical phenotypes and possible genetic underpinnings were recognized in this cohort of pediatric CNS hemophagocytic lymphohistiocytosis. Disruptive mutations and missense mutations with absent protein expression correlate with a younger onset age. Children with brainstem and cerebellitis patterns and a negative etiologic work-up require directed assessment for CNS hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- P Malik
- From the Departments of Diagnostic Imaging (P. Malik, P. Mannam, S.E.M.)
| | - L Antonini
- Department of Paediatric Hemato-Oncology (L.A.), G. Salesi Hospital, Ancona, Italy
| | - P Mannam
- From the Departments of Diagnostic Imaging (P. Malik, P. Mannam, S.E.M.)
| | | | - A Merve
- Department of Histopathology (A.M.)
| | | | - K Rao
- Bone Marrow Transplant Unit (K.R.)
| | - S Kumar
- Child Heath (S.K.), Christian Medical College, Vellore, India
| | - S E Mani
- From the Departments of Diagnostic Imaging (P. Malik, P. Mannam, S.E.M.)
| | - D Eleftheriou
- Paediatric Rheumatology (D.E.), Great Ormond Street Hospital for Children and University College, London, UK
| | - A Rao
- Department of Pediatric Hematology (A.R., J.B.)
| | | | | | - J Bartram
- Department of Pediatric Hematology (A.R., J.B.)
| | - K Mankad
- Pediatric Neuroradiology Unit (S.V.S., K.M.)
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Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids May Extend above and below Pons and Is Associated with Other Autoimmune Diseases. Life (Basel) 2021; 11:life11111120. [PMID: 34832996 PMCID: PMC8621219 DOI: 10.3390/life11111120] [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: 08/27/2021] [Revised: 10/16/2021] [Accepted: 10/19/2021] [Indexed: 11/22/2022] Open
Abstract
Many autoimmune diseases can affect the central nervous system, and their varying clinical presentations often confound a straightforward diagnosis. In this report, we describe a unique presentation of CLIPPERS syndrome. To our knowledge, this is the first case to demonstrate significant supratentorial involvement with symmetric and non-confluent lesions in the medial orbitofrontal cortex; additionally, this is the second case to describe an association between diagnoses of hypothyroidism and CLIPPERS.
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El Jammal T, Jamilloux Y, Gerfaud-Valentin M, Richard-Colmant G, Weber E, Bert A, Androdias G, Sève P. Challenging Mimickers in the Diagnosis of Sarcoidosis: A Case Study. Diagnostics (Basel) 2021; 11:1240. [PMID: 34359324 PMCID: PMC8304686 DOI: 10.3390/diagnostics11071240] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 12/19/2022] Open
Abstract
Sarcoidosis is a systemic granulomatous disease of unknown cause characterized by a wide variety of presentations. Its diagnosis is based on three major criteria: a clinical presentation compatible with sarcoidosis, the presence of non-necrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. Many conditions may mimic a sarcoid-like granulomatous reaction. These conditions include infections, neoplasms, immunodeficiencies, and drug-induced diseases. Moreover, patients with sarcoidosis are at risk of developing opportunistic infections or lymphoma. Reliably confirming the diagnosis of sarcoidosis and better identifying new events are major clinical problems in daily practice. To address such issues, we present seven emblematic cases, seen in our department, over a ten-year period along with a literature review about case reports of conditions misdiagnosed as sarcoidosis.
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Affiliation(s)
- Thomas El Jammal
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Gaëlle Richard-Colmant
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Emmanuelle Weber
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Arthur Bert
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Géraldine Androdias
- Department of Neurology, Service Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Lyon University Hospital, F-69677 Bron, France;
| | - Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
- Research on Healthcare Performance (RESHAPE), INSERM U1290, 69373 Lyon, France
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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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Picarelli H, Yamaki VN, Casal YR, de Brito MH, de Lima LGCA, Ayres AS, de Oliveira MCB. CLIPPERS With Exclusive Extra Pontine Involvement. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/3/e989. [PMID: 33771838 PMCID: PMC8075571 DOI: 10.1212/nxi.0000000000000989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/20/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Helder Picarelli
- From the Department of Surgery (H.P.), Department of Surgery (V.N.Y.), Division of Anatomical Pathology (Y.R.C.), Neurology Unit (M.H.d.B), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Division of Anatomical Pathology (L.G.C.A.L.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Department of Diagnostic Imaging (A.S.A.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Neurology Unit (M.C.B.O.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil.
| | - Vitor Nagai Yamaki
- From the Department of Surgery (H.P.), Department of Surgery (V.N.Y.), Division of Anatomical Pathology (Y.R.C.), Neurology Unit (M.H.d.B), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Division of Anatomical Pathology (L.G.C.A.L.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Department of Diagnostic Imaging (A.S.A.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Neurology Unit (M.C.B.O.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil
| | - Yuri Reis Casal
- From the Department of Surgery (H.P.), Department of Surgery (V.N.Y.), Division of Anatomical Pathology (Y.R.C.), Neurology Unit (M.H.d.B), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Division of Anatomical Pathology (L.G.C.A.L.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Department of Diagnostic Imaging (A.S.A.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Neurology Unit (M.C.B.O.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil
| | - Marcelo Houat de Brito
- From the Department of Surgery (H.P.), Department of Surgery (V.N.Y.), Division of Anatomical Pathology (Y.R.C.), Neurology Unit (M.H.d.B), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Division of Anatomical Pathology (L.G.C.A.L.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Department of Diagnostic Imaging (A.S.A.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Neurology Unit (M.C.B.O.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil
| | - Luiz Guilherme Cernaglia Aureliano de Lima
- From the Department of Surgery (H.P.), Department of Surgery (V.N.Y.), Division of Anatomical Pathology (Y.R.C.), Neurology Unit (M.H.d.B), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Division of Anatomical Pathology (L.G.C.A.L.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Department of Diagnostic Imaging (A.S.A.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Neurology Unit (M.C.B.O.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil
| | - Aline Sgnolf Ayres
- From the Department of Surgery (H.P.), Department of Surgery (V.N.Y.), Division of Anatomical Pathology (Y.R.C.), Neurology Unit (M.H.d.B), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Division of Anatomical Pathology (L.G.C.A.L.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Department of Diagnostic Imaging (A.S.A.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Neurology Unit (M.C.B.O.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil
| | - Marcos Castello Barbosa de Oliveira
- From the Department of Surgery (H.P.), Department of Surgery (V.N.Y.), Division of Anatomical Pathology (Y.R.C.), Neurology Unit (M.H.d.B), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Division of Anatomical Pathology (L.G.C.A.L.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Department of Diagnostic Imaging (A.S.A.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil; Neurology Unit (M.C.B.O.), Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Brazil
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Deng Y, Zhao B, Wei B, Zhang S, Liu M. Parotid carcinoma following chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids: a case report. BMC Neurol 2021; 21:110. [PMID: 33691619 PMCID: PMC7944626 DOI: 10.1186/s12883-021-02135-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 03/02/2021] [Indexed: 02/08/2023] Open
Abstract
Background Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory disorder with unclear causes. Paraneoplastic etiology may be a cause. We report a case of CLIPPERS with parotid carcinoma. Case presentation A 54-year-old man with a history of lymphoma was hospitalized with a pontocerebellar syndrome. Brain MRI revealed that the pons and cerebellum were “peppered” with punctate and curvilinear enhancement lesions that supported the diagnosis of CLIPPERS. The relapse of lymphoma was excluded by a further cerebellum biopsy revealing predominantly CD3+ T cells in white matter. The patient was relieved after pulse therapy with intravenous methylprednisolone and a large dose of corticosteroids, but he complained of a worsening gait problem when corticosteroids were tapered to a lower dose. Although the clinical symptoms gradually improved again by increasing the dosage of corticosteroids with Azathioprine, the patient still had a slight unsteady gait during follow-up. At the 7-month follow-up, a parotid mass was detected by MRI and was verified as carcinoma by biopsy. After resection of parotid carcinoma, the residual symptoms and previous MRI lesions disappeared, and no relapse occurred. Conclusions CLIPPERS may not be a distinct nosologic entity but an overlapping diagnosis with other diseases. Some cases of CLIPPERS might be a subtype of paraneoplastic neurological syndromes (PNS) due to the similar mechanism of antibody-mediated encephalitis. Tumor screening and serum paraneoplastic autoantibody tests are recommended for patients with CLIPPERS, especially for those who relapse when corticosteroids treatment is stopped or tapered. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02135-6.
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Affiliation(s)
- Yilun Deng
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bi Zhao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bing Wei
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shihong Zhang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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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: 13] [Impact Index Per Article: 4.3] [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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Obeidat AZ, Block AN, Hooshmand SI. "Peppering the pons": CLIPPERS or myelin oligodendrocyte glycoprotein associated disease? Mult Scler Relat Disord 2021; 51:102874. [PMID: 33714127 DOI: 10.1016/j.msard.2021.102874] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/13/2021] [Accepted: 02/28/2021] [Indexed: 11/24/2022]
Abstract
Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a distinct pathologic entity of unknown etiology. Here, we describe the clinical and radiologic presentation of myelin oligodendrocyte glycoprotein associated disease (MOG-AD) with features mimicking CLIPPERS. Three patients met the 2017 CLIPPERS diagnostic criteria, while one patient had a single lesion in the pons that mimicked CLIPPERS lesions. All had an excellent response to steroids, but the three who met the CLIPPERS criteria had a relapsing course. When CLIPPERS is observed, it is crucial to test for mimickers. The ever-expanding spectrum of MOG-AD calls for further research into the immunopathogenesis of its several phenotypes.
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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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Chronic lymphocytic infiltration with pontine perivascular enhancement responsive to steroids (CLIPPERS) and its association with Epstein-Barr Virus (EBV)-related lymphomatoid granulomatosis: a case report. BMC Neurol 2021; 21:80. [PMID: 33602163 PMCID: PMC7890986 DOI: 10.1186/s12883-021-02110-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic lymphocytic infiltration with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a neuro-inflammatory syndrome first described in 2010. It has a relationship with lymphoproliferative disorders that has not been fully elucidated. This case represents an unusual progression of CLIPPERS to Epstein-Barr Virus (EBV)-related lymphomatoid granulomatosis (LYG). The exact connection between CLIPPERS and LYG remains poorly understood. CASE PRESENTATION We present a case of a 75-year-old man who was diagnosed with CLIPPERS with initial response to immunosuppression but later progressed to EBV-related LYG. EBV polymerase chain reaction (PCR) was detected in his cerebrospinal fluid (CSF), and repeat imaging revealed findings that were uncharacteristic for CLIPPERS; thereby prompting a brain biopsy which led to a diagnosis of EBV-related LYG. This case highlights the following learning points: 1) CLIPPERS cases are often part of a spectrum of lymphomatous disease, 2) CLIPPERS can be associated with EBV-related lymphoproliferative disorders such as LYG, and 3) EBV detection in CSF should prompt earlier consideration for brain biopsy in patients. CONCLUSIONS Our case highlights the difficulty in distinguishing CLIPPERS from other steroid-responsive conditions such as neoplastic and granulomatous diseases. Given the association of CLIPPERS with EBV-related LYG as demonstrated in this case, we recommend testing for EBV in CSF for all patients with suspected CLIPPERS. An early referral for brain biopsy and treatment with rituximab should be considered for patients with suspected CLIPPERS who test positive for EBV in their CSF.
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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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Martin T, Duke S, Kumar V, Fadhil A, Ibrahim R, Palmer K, Yazdani S, Devereaux M, Gunzler S, Serra A, Abboud H. NMDAR antibody encephalitis overlapping with CLIPPERS syndrome in a psoriasis patient on adalimumab. J Neurol 2021; 268:714-716. [PMID: 33388924 DOI: 10.1007/s00415-020-10341-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 11/27/2020] [Accepted: 12/04/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Talora Martin
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Sean Duke
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Veena Kumar
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Ali Fadhil
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Rami Ibrahim
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Kaitlin Palmer
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Saad Yazdani
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Michael Devereaux
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Steven Gunzler
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Alessandro Serra
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA.,VA Multiple Sclerosis Center of Excellence, Cleveland VA Medical Center, Cleveland, OH, USA.,Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA
| | - Hesham Abboud
- Neurology Department, University Hospitals of Cleveland, Cleveland Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, USA. .,Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA.
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Iovino A, Del Vecchio W, Aruta F, Iodice R. CLIPPERS. Pract Neurol 2020; 21:practneurol-2020-002857. [PMID: 33376153 DOI: 10.1136/practneurol-2020-002857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 11/03/2022]
Abstract
We present the clinical case of a woman suffering from CLIPPERS syndrome (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids). The images obtained from the brain magnetic resonance show the lesions typical of the disease.
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Affiliation(s)
- Aniello Iovino
- Department of Neurosciences, Reproductive and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Walter Del Vecchio
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Francesco Aruta
- Department of Neurosciences, Reproductive and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Rosa Iodice
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
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Yin HX, Zhou Y, Xu Y, Li ML, Zhang Z, Zhou LX, Zhang Y, Zhu YC, Peng B, Cui LY. A Case Report of Autoimmune Glial Fibrillary Acidic Protein Astrocytopathy Diagnosed After Long Term Diagnosis of Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids. Front Neurol 2020; 11:598650. [PMID: 33281735 PMCID: PMC7705065 DOI: 10.3389/fneur.2020.598650] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
Cases of autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy who were initially diagnosed with chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) were rarely reported. Herein, we reported a 31-year-old woman who presented with 7 years of recurrent headache. Her clinical history, symptoms, brain MRI enhancement features, and response to treatment during each attack were reviewed. Her brain MRI 7 years ago demonstrated characteristic pepper-like enhancement of pontine and cerebellum and her symptoms resolved completely after taking a high-dose of steroids. She was suspected with the diagnosis of CLIPPERS, and she experienced five relapses once the oral steroid was tapered below 20 mg/day. During her last relapse, she experienced fever and psychosis, and GFAPα-antibodies were detected in her serum and cerebrospinal fluid by antigen-transfected HEK293 cell-based assay (indirect immunofluorescence assay). She obtained relief again after steroid therapy, and her diagnosis converted to autoimmune GFAP astrocytopathy. Autoimmune GFAP astrocytopathy may mimic CLIPPERS, both clinically and radiologically. Long-term follow-up is essential for necessary diagnosis revision at each new attack in patients with a diagnosis of CLIPPERS.
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Affiliation(s)
- He-Xiang Yin
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Zhou
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Xu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Li Li
- Department of Radiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhe Zhang
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Xin Zhou
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yao Zhang
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi-Cheng Zhu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Peng
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Ying Cui
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Neurosciences Center, Chinese Academy of Medical Sciences, Beijing, China
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Sotoudeh H, Razaei A, Saadatpour Z, Gaddamanugu S, Choudhary G, Shafaat O, Singhal A. Brainstem Encephalitis. The Role of Imaging in Diagnosis. Curr Probl Diagn Radiol 2020; 50:946-960. [PMID: 33032853 DOI: 10.1067/j.cpradiol.2020.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 01/19/2023]
Abstract
Encephalitis is a relatively challenging rare condition caused by a diverse group of etiologies. Brainstem encephalitis/Rhombencephalitis (BE), which affects the cerebellum, pons, and medulla, is even less common and more challenging for diagnosis and treatment. At this time, there is scattered data about BE in the literature, mainly in the form of case reports and case series. In this manuscript, the imaging presentation of BE is reviewed with the help of case examples. Many imaging presentations are not pathognomonic for BE; however, in many cases, clinical presentation, the spatial distribution of lesions, and other associated radiological lesions can provide the radiologists and clinician the clues to an accurate diagnosis.
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Affiliation(s)
| | - Ali Razaei
- Department of Neuroradiology, University of Alabama at Birmingham (UAB), Birmingham, AL
| | - Zahra Saadatpour
- Department of Neuroradiology, University of Alabama at Birmingham (UAB), Birmingham, AL
| | | | | | - Omid Shafaat
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aparna Singhal
- University of Alabama at Birmingham (UAB), Birmingham, AL
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40
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Yuen CA, Rezania K, Park DM, Reder AT. Asymptomatic brainstem lesions and pachymeningeal enhancement after anti-PD-1 therapy. Immunotherapy 2020; 13:11-17. [PMID: 33023359 DOI: 10.2217/imt-2020-0186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Neurological immune-related adverse events (irAEs) are rare toxicities that occur following immune checkpoint inhibitor therapy. We propose that patients with thymic malignancies and graft-versus-host disease (GVHD) are predisposed to irAEs. We present two asymptomatic patients, one with thymoma and another with GVHD, who developed abnormal brain MRIs after treatment with programmed cell death protein 1 inhibitors. The first patient, with thymic cancer and thymoma, developed pontine enhancing MRI lesions following treatment with pembrolizumab. The second patient, with prior GVHD, developed pachymeningeal enhancement following treatment with nivolumab. IrAEs with abnormal MRI studies, despite asymptomatology, have significant impact on the treatment strategy for these patients.
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Affiliation(s)
- Carlen A Yuen
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Kourosh Rezania
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Deric M Park
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Anthony T Reder
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA
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A case of diffuse large B cell lymphoma initially presenting as CLIPPERS: possible role of the Epstein-Barr virus. Neurol Sci 2020; 42:1199-1202. [PMID: 32995991 DOI: 10.1007/s10072-020-04750-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/19/2020] [Indexed: 10/23/2022]
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42
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Zhang W, Cui L, Dong M, Tian Z, Jiao Y, Jiao J. Area Postrema Syndrome: A Rare Feature of Chronic Lymphocytic Inflammation With Pontine Perivascular Enhancement Responsive to Steroids. Front Neurol 2020; 11:730. [PMID: 32973644 PMCID: PMC7461882 DOI: 10.3389/fneur.2020.00730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 06/15/2020] [Indexed: 11/15/2022] Open
Abstract
Background: The area postrema syndrome (APS) is a unique diagnostic criterion for neuromyelitis optica spectrum disorders (NMOSD). However, APS has rarely been reported in cases of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS). Case presentation: A 36-year-old woman presented with APS and clinical features of diffuse central nervous system involvement during the early stage of the disease. Owing to the absence of serum aquaporin 4 antibodies, she was initially misdiagnosed as a case of seronegative NMOSD. However, the distinct neuroimaging characteristics [symmetrical small punctuate gadolinium enhancing lesions (pepper-like)], typical clinical/radiological relapse, and intense steroid-dependence in this case, prompted us to correct the diagnosis as probable CLIPPERS. To prevent relapse, long-term oral steroids and an immunosuppressive agent were administered. Conclusions: CLIPPERS may present as APS, and should be considered in the differential diagnosis of NMOSD.
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Rauschenbach L, Kebir S, Radbruch A, Darkwah Oppong M, Gembruch O, Teuber-Hanselmann S, Gielen GH, Scheffler B, Glas M, Sure U, Lemonas E. Challenging Implications of Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids Syndrome with an Atypical Presentation: Report of Two Cases. World Neurosurg 2020; 143:507-512.e1. [PMID: 32711135 DOI: 10.1016/j.wneu.2020.07.123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an increasingly recognized neuroinflammatory syndrome that predominantly affects the pontine and cerebellar brain structures. Characteristically, patients will develop glucocorticoid-responsive brainstem disorders, demonstrate pontocerebellar contrast enhancement on magnetic resonance imaging (MRI), and exhibit an angiocentric, lymphocytic infiltrate in brain biopsies. We have presented and discussed 2 novel and challenging cases of CLIPPERS syndrome to highlight the clinical and radiological diversity of the syndrome. CASE DESCRIPTION The first case was of a 66-year-old male patient who had presented with dizziness, headaches, gait disturbances, mild cognitive impairment, and visual field loss to the left side. MRI revealed 1 cerebellar and 2 occipital contrast-enhancing lesions that were suspicious for intracerebral metastases. The second case was of a 53-year-old male patient who had presented with temporal lobe epilepsy, anomic aphasia, and mild cognitive impairment. MRI demonstrated 4 contrast-enhancing lesions in the pons, temporal lobe, and thalamus that were suspicious for intracerebral lymphoma. Because of the radiological presentation, neoplastic disease was the most plausible diagnosis for both patients. However, repeated biopsies ruled out tumor manifestation, and the findings were finally consistent with CLIPPERS syndrome. The significant and long-lasting response to immunosuppressive treatment confirmed the diagnosis. CONCLUSIONS In both cases, the characteristics of CLIPPERS syndrome imitated malignant tumor growth. This scenario can be challenging to clinicians and necessitates inclusion of this neuroinflammatory syndrome in the differential diagnosis of neuro-oncological disease.
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Affiliation(s)
- Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany; Division of Translational Neurooncology, West German Cancer Center, German Cancer Consortium Partner Site, University Hospital Essen, Essen, Germany.
| | - Sied Kebir
- Division of Translational Neurooncology, West German Cancer Center, German Cancer Consortium Partner Site, University Hospital Essen, Essen, Germany; Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, Essen, Germany
| | - Alexander Radbruch
- Division of Neuroradiology, Institute for Diagnostic and Interventional Radiology, University Hospital Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Oliver Gembruch
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | | | - Gerrit H Gielen
- Institute of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Björn Scheffler
- Division of Translational Neurooncology, West German Cancer Center, German Cancer Consortium Partner Site, University Hospital Essen, Essen, Germany
| | - Martin Glas
- Division of Translational Neurooncology, West German Cancer Center, German Cancer Consortium Partner Site, University Hospital Essen, Essen, Germany; Division of Clinical Neurooncology, Department of Neurology, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Elias Lemonas
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
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Diagnostic and therapeutic issues of inflammatory diseases of the elderly. Rev Neurol (Paris) 2020; 176:739-749. [PMID: 32312496 DOI: 10.1016/j.neurol.2020.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/24/2022]
Abstract
Inflammatory diseases of the central nervous system (CNS) mainly occur during early adulthood and multiple sclerosis (MS) represents the overwhelming majority of these disorders. Nevertheless, MS only rarely begins after 50 years and a diagnosis of late-onset MS should only be done when clinical as well as radiological and biological findings are typical of MS since the probability of misdiagnosis is higher in elderly patients. Indeed, in patients aged over 50 years, along with a relative decrease of MS incidence, other inflammatory diseases of the CNS but also differential diagnoses including neoplastic as well as infectious disorders should be thoroughly searched to avoid diagnostic mistakes and the prescription of inadequate and potentially harmful immunomodulatory/immunosuppressive therapies. Moreover, aging is associated with diverse immune changes also known as immunosenescence resulting in, notably, higher risk of comorbidities (including vascular diseases) and infections which need to be considered when planning medical treatments of elderly patients with inflammatory diseases of the CNS. Herein, therapeutic and diagnostic challenges faced by neurologists are reviewed to ease patient management.
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Li Z, Jiang Z, Ouyang S, Li Y, Yang H. CLIPPERS, a syndrome of lymphohistiocytic disorders. Mult Scler Relat Disord 2020; 42:102063. [PMID: 32234602 DOI: 10.1016/j.msard.2020.102063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 03/15/2020] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is a chronic central nervous system (CNS) inflammatory disorder. It may be associated with lymphoma and macrophage activation, while the related report of histiocytes (macrophage) activation involved in pathogenesis of CLIPPERS is rare. We present the first "probable CLIPPERS" case associated with histiocytic sarcoma (HS) progressed to hemophagocytic syndrome (HPS) in a 38-year-old man patient. CASE PRESENTATION The 38-year-old man presented with facial numbness, diplopia, gait ataxia and glossolalia for 29 months. Brain MRI showed gadolinium enhancement peppering the pons and extending into the midbrain, medulla, brachium pontis, cerebellum and thalamus. The patient's CNS symptoms were improved significantly and accompanied by marked radiological improvement after glucocorticoids therapy, while the disease courses presented relapsing-remitting and glucocorticoids-dependent. Multiple nodules in the abdomen were accidentally discovered by the abdominal Computed tomography (CT) during the remission period. HS was diagnosed by histological examination of the abdominal node biopsy accompanied by CLIPPERS relapse, and eventually progressed to HPS. CONCLUSIONS CLIPPERS could be a syndrome of lymphohistiocytic disorders.
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Affiliation(s)
- Zhibin Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Zhiping Jiang
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Song Ouyang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
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Bot JC, Mazzai L, Hagenbeek RE, Ingala S, van Oosten B, Sanchez-Aliaga E, Barkhof F. Brain miliary enhancement. Neuroradiology 2020; 62:283-300. [PMID: 31925469 PMCID: PMC7044143 DOI: 10.1007/s00234-019-02335-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/04/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Miliary enhancement refers to the presence of multiple small, monomorphic, enhancing foci on T1-weighted post-contrast MRI images. In the absence of a clear clinical presentation, a broad differential diagnosis may result in invasive procedures and possibly brain biopsy for diagnostic purposes. METHODS An extensive review of the literature is provided for diseases that may present with miliary enhancement on T1-weighted brain MR images. Additional disease-specific findings, both clinical and radiological, are summarized and categorized by the presence or absence of perivascular space involvement. RESULTS Miliary pattern of enhancement may be due to a variety of underlying causes, including inflammatory, infectious, nutritional or neoplastic processes. The recognition of disease spread along the perivascular spaces in addition to the detection or exclusion of disease-specific features on MRI images, such as leptomeningeal enhancement, presence of haemorrhagic lesions, spinal cord involvement and specific localisation or systemic involvement, allows to narrow the potential differential diagnoses. CONCLUSION A systematic approach to disease-specific findings from both clinical and radiological perspectives might facilitate diagnostic work-up, and recognition of disease spread along the perivascular spaces may help narrowing down differential diagnoses and may help to minimize the use of invasive diagnostic procedures.
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Affiliation(s)
- Joseph C.J. Bot
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - Linda Mazzai
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
- Institute of Radiology, Department of Medicine (DiMED), University of Padua, Padua, Italy
| | | | - Silvia Ingala
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - Bob van Oosten
- Department of Neurology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Esther Sanchez-Aliaga
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
- Institute of Neurology and Healthcare Engineering, UCL, London, UK
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