23-year-old Filipino lady, previously healthy, presented to the emergency department with vertigo and imbalance in walking of six days prior to admission; her symptoms were also associated with blurring of vision, diplopia, and headache, in addition to numbness in the lower limbs initially that resolved at the time of presentation. The patient denied history of fever, sweating, or weight loss and history of orogenital ulcers or arthralgia. There was no personal or family history of thrombotic events and she was nonalcoholic. On examination, patient was conscious, oriented, and alert, with apparent right sided and upward jerky nystagmus, but normal range of motion of both eyes, normal pupillary reflexes, and fundoscopy; patient was found to have loss of coordination in the four limbs manifested by abnormal finger nose test and dysdiadokinesia, with abnormal heal shin test, that was more marked on the left side; otherwise motor, tone, touch, and position sensation were all intact.
MRI of the brain and spinal cord showed evidence of multiple foci of faint bright signal intensity involving the posterior pons and left brachium pontis (Figure 1), with superior extension extending to cerebral subcortical and deep white matter, bilateral thalami, and basal ganglia (Figure 2), and inferior extension along the spinal cord at multiple levels (Figure 3), with small punctate enhancement that aligned along fine curvilinear enhancing structures; given the typical features, the possibility of CLLIPPERS was raised by the radiologist.
Cerebrospinal fluid study (CSF) showed lymphocytic pleocytosis (WBC: 12, lymphocyte 98%) with normal protein and glucose, and viral serology for HSV1, HSV2, CMV, EBV, VZV, mumps, adenovirus, enterovirus, and parechovirus were negative.
CSF Gram stain and culture were negative. CSF TB PCR and VDRL were nonreactive. Complete blood count and peripheral smear were normal; HIV and Quantiferon TB were also negative. CSF oligoclonal band was negative, in addition to normal visual evoked potential; both made multiple sclerosis unlikely. Antinuclear antibodies were found to be positive (1 : 320, nucleolar in pattern) but anti-double stranded antibodies and anti-cardiolipin antibodies were negative; accordingly the probability of having autoimmune disease without any suggestive symptoms was rather low.
Our patient showed some spontaneous improvement; however, following the institution of steroids with a 60 mg of prednisolone she responded dramatically and started to walk with improvement of balance, nystagmus resolved, and coordination improved significantly. After 2 weeks of prednisolone as outpatient, she returned back to normal functioning, free of any symptom, with completely normal neurological exam.