Age: 80.0
Sex: M
Vaccine: FLUX, FLU3
Symptoms: Lymphocytic infiltration, Mycobacterium test negative, Nuclear magnetic resonance imaging brain abnormal, Paraesthesia, Red blood cell sedimentation rate normal
Clinical narrative: This case was reported in a literature article and described the occurrence of lymphocytic inflammatory infiltrates (Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS)) in a 80-year-old male subject who was vaccinated with Influenza vaccine (manufacturer unspecified). Concurrent medical conditions included hypercholesterolemia and hypertension. The subject reported having fatigue and diminished appetite without weight loss in the preceding year. In 2010, the subject received an unspecified dose of Influenza vaccine (unknown route and injection site, batch number not provided). In October 2010, 2 weeks after vaccination with Influenza vaccine, the subject experienced numbness and paresthesia in his right hand. 3 weeks after vaccination with Influenza vaccine, the subject's right lower extremity and left foot were similarly affected. He also noticed a change in his voice, numbness of his face, and a wobbly gait. He reported no recent rashes, fever, neck stiffness, joint pains, or other systemic manifestations apart from a decrease in bowel movement frequency. The subject was hospitalized. A computed tomography scan of his chest, abdomen, and pelvis revealed a tumor in the right kidney. Laparoscopic resection demonstrated a renal cell carcinoma. Physical examination showed a hoarse voice, an ocular motility characterized by saccadic intrusions and impaired vertical gaze upwards, a mildly ataxic gait, and diminished sensation in his distal lower extremities. On 19 November 2010, cranial magnetic resonance imaging (MRI) performed, showed a fairly homogeneously enhancing lesion within the central pons, within a larger area of increased signal on the fluid-attenuated inversion recovery (FLAIR). The enhancement around the periphery of the lesion was somewhat punctate or speckled. In December 2010, a biopsy specimen of the pontine lesion showed a reactive, T-cell-predominant, CD3-positive, lymphocytic infiltrate with scattered macrophages and microglial cells with few plasma cells. There were no microglial nodules identified. Occasional p53- and Ki-67-positive atypical astrocytes and gliosis were noted. There were no viral inclusions or infectious agents on hematoxylin-eosin staining. No organisms were identified with Grocott methenamine silver staining and acid-fast bacteria staining, and viral immunohistochemistry findings for herpes simplex virus and human herpesvirus 8 were negative. An anti-cytokeratin (CAM 5.2) immunostain was performed because of the diagnosis of renal cell carcinoma but showed only nonspecific background staining. A luxol fast blue stain to access demyelination yielded negative results, and negative in situ hybridization findings were noted for Epstein-Barr virus encoded RNA. Flow cytometry failed to reveal a monoclonal B lymphocyte population. A lumbar puncture was performed and showed clear and colorless fluid. The cerebral spinal fluid cytology showed 5 white blood cells with 70% mononuclear cells; protein, 22 mg/dL; glucose, 72 ng/dL; and lactic acid, 2 mmol/L. The lactate dehydrogenase level in the cerebral spinal fluid was 26 IU/L. Venereal disease research laboratory test result was non-reactive. The subject's erythrocyte sedimentation rate was 5 mm/h and anti-nuclear antibody, anti-Sjogren antibodies, and other serologic screening test results were normal. 1 month later, a repeated brain magnetic resonance imaging was performed and showed little change. After pontine biopsy, the subject was given dexamethasone 4 mg, four times daily, which was continued for 1 week. On 5 January 2011, although no clinical improvement was evident in the interim, a repeated brain magnetic resonance imaging was performed and showed decreased enhancement of the pontine lesion. In May 2011, clinical and radiographic features improved when he received a course of intravenous methylprednisolone, 1 gram daily for 5 days, followed by oral prednisone 60 mg daily with gradual tapering. On 23 June 2011, a brain magnetic resonance imaging showed significant improvement in the contrast-enhancing lesions in the pons; however, the subject continued to have complaints of a glovelike paresthesia and had an ataxic gait. Methotrexate 15 mg weekly was initiated to accompany prednisone 20 mg every other day. The subject did not received chemotherapy or radiation therapy. At the time of reporting, the renal carcinoma and the Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids (CLIPPERS) were improved, the numbness in hand and hand paresthesia were unresolved and outcome of the other events was unspecified.