Posterior reversible encephalopathy syndrome (PRES) in the course of immunosuppressive therapy in A 45-year-old male with normal blood pressure – case study

Objective: During the late 2019, a group of patients had unexplained chest infections in Wuhan which turned out to be the new pandemic coronavirus disease 2019 (COVID-19). New neurological symptoms have been reported in COVID-19 patients. Posterior reversible encephalopathy syndrome (PRES) is a new neurological finding and is associated or caused by COVID-19. Case Presentation: A 32-year-old lady, with no medical background had COVID-19 infection and needed mechanical ventilation. After surviving the intensive care, she started to have multiple seizures that required general anesthesia to be aborted. The patient turned out to have PRES. Conclusion: PRES is a neurological syndrome causing seizures, headaches, and blurred vision. It is usually associated with high blood pressure, renal failure, and other risk factors. The patient in this case had nearly normal blood pressure, but still had a diagnosis of PRES. The new reported neurological symptoms associated with COVID-19 infection need further research and attention from the academic society to predict and prevent the morbidity and mortality of COVID-19 patients.

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Posterior reversible encephalopathy syndrome in a patient with underlying mixed connective tissue disease

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20182819 ◽

2018 ◽

Vol 6 (7) ◽

pp. 2551

Author(s):

Malyaban Das ◽

Prajit Mazumdar ◽

Divakar Kumar ◽

Vaibhav Mathur

Keyword(s):

Blood Pressure ◽

Connective Tissue ◽

Connective Tissue Disease ◽

Posterior Reversible Encephalopathy Syndrome ◽

Mixed Connective Tissue Disease ◽

Altered Mental Status ◽

Normal Blood Pressure ◽

Posterior Reversible Encephalopathy ◽

Reversible Encephalopathy ◽

Visual Disturbances

Posterior reversible encephalopathy syndrome (PRES) is a condition which is characterized by symmetric involvement of posterior white matter on brain imaging and neurological impairments such as seizures, altered mental status, headache, and visual disturbances. This entity has been classically described with hypertension, renal failure and eclampsia but it can also been seen in cases with normal blood pressure especially in patients receiving immunosuppressive therapy, chemotherapy and in patients with underlying autoimmune disease. Although PRES has been reported with several autoimmune disorders, association of Posterior reversible encephalopathy syndrome (PRES) with mixed connective tissue disease (MCTD) is very rare, hence we report a case of Posterior reversible encephalopathy syndrome in a patient with underlying mixed connective tissue disease (MCTD).

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Posterior reversible encephalopathy syndrome in Parkinson disease probably caused by prominent supine hypertension and blood pressure fluctuation

Rinsho Shinkeigaku ◽

10.5692/clinicalneurol.cn-000907 ◽

2016 ◽

Vol 56 (11) ◽

pp. 754-758 ◽

Cited By ~ 2

Author(s):

Saori Morozumi ◽

Shigenori Kato ◽

Keizo Yasui ◽

Yasuhiro Hasegawa

Keyword(s):

Blood Pressure ◽

Parkinson Disease ◽

Posterior Reversible Encephalopathy Syndrome ◽

Pressure Fluctuation ◽

Supine Hypertension ◽

Posterior Reversible Encephalopathy ◽

Blood Pressure Fluctuation ◽

Reversible Encephalopathy

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A rare case of posterior reversible encephalopathy syndrome in a patient with severe leptospirosis complicated with rhabdomyolysis and acute kidney injury; a case report

BMC Infectious Diseases ◽

10.1186/s12879-021-06240-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jayawardane Pathiranage Roneesha Lakmali ◽

Kanapathipillei Thirumavalavan ◽

Danapala Dissanayake

Keyword(s):

Blood Pressure ◽

Acute Kidney Injury ◽

Blood Pressure Control ◽

Posterior Reversible Encephalopathy Syndrome ◽

Vision Loss ◽

Kidney Injury ◽

Pressure Control ◽

Posterior Reversible Encephalopathy ◽

Peripheral Nerve Involvement ◽

Reversible Encephalopathy

Abstract Background Leptospirosis is a zoonotic spirochetal disease caused by Leptospira interrogans. The clinical presentation ranges from an asymptomatic state to a fatal multiorgan dysfunction. Neurological manifestations including aseptic meningitis, spinal cord and peripheral nerve involvement, cranial neuropathies and cerebellar syndrome are well recognized with varying frequencies among patients with this disease. Posterior reversible encephalopathy syndrome is a very rare occurrence in leptospirosis and only two cases are reported in the medical literature up to now. We report a case of posterior reversible encephalopathy syndrome in a patient with leptospirosis with rhabdomyolysis and acute kidney injury. Case presentation A 21 year-old male presented with fever and oliguric acute kidney injury with rhabdomyolysis. A diagnosis of leptospirosis was made and he was being managed according to the standard practice together with regular hemodialysis. The clinical condition was improving gradually. On day 8 of the illness, he developed headache and sudden painless complete bilateral vision loss followed by several brief generalized tonic clonic seizure attacks. Examination was significant for a Glasgow Coma Scale of 14/15, blood pressure of 150/90 mmHg and complete bilateral blindness. The findings of magnetic resonance imaging of the brain were compatible with posterior reversible encephalopathy syndrome. He was managed with blood pressure control and antiepileptics with supportive measures and standard treatment for leptospirosis and made a complete recovery. Conclusion Posterior reversible encephalopathy syndrome, though very rare with leptospirosis, should be considered as a differential diagnosis in a patient with new onset visual symptoms and seizures, especially during the immune phase. Optimal supportive care together with careful blood pressure control and seizure management would yield a favourable outcome in this reversible entity.

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Posterior Reversible Encephalopathy Syndrome: A Case of Hypercalcemia

Acta Médica Portuguesa ◽

10.20344/amp.9714 ◽

2018 ◽

Vol 31 (6) ◽

pp. 338

Author(s):

Ana Ponciano ◽

Vera Vieira ◽

José Leite ◽

Célio Fernandes

Keyword(s):

Renal Failure ◽

Immunosuppressive Therapy ◽

Mental Status ◽

Posterior Reversible Encephalopathy Syndrome ◽

Altered Mental Status ◽

Normotensive Patient ◽

Posterior Reversible Encephalopathy ◽

Severe Hypercalcemia ◽

Reversible Encephalopathy

Posterior reversible encephalopathy syndrome is an encephalopathy that can be clinically characterized by headache, altered mental status and/or seizures. Neuroimaging demonstrates usually reversible bilateral subcortical vasogenic occipital-parietal edema. Exact pathophysiology remains unclear but is commonly associated with hypertension, renal failure, sepsis and use of immunosuppressive therapy. Its development in the setting of severe hypercalcemia is extremely rare. The authors report a case of posterior reversible encephalopathy syndrome in a normotensive patient with severe hypercalcemia as the only identifiable cause.

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A Rare Neurological Complication - Posterior Reversible Encephalopathy Syndrome in a Patient with Systemic Lupus Erythematosus and Class IV Lupus Nephritis

Internal Medicine ◽

10.2478/inmed-2018-0027 ◽

2018 ◽

Vol 15 (4) ◽

pp. 27-34

Author(s):

Anna Mirela Stroie ◽

Mircea Nicolae Penescu

Keyword(s):

Systemic Lupus Erythematosus ◽

Lupus Nephritis ◽

Immunosuppressive Therapy ◽

Posterior Reversible Encephalopathy Syndrome ◽

Lupus Erythematosus ◽

Neurological Complication ◽

Systemic Lupus ◽

Posterior Reversible Encephalopathy ◽

Reversible Encephalopathy ◽

Class Iv

AbstractPosterior reversible encephalopathy syndrome is a rare manifestation of systemic lupus erythematosus, characterized by altered mental status, headache, convulsions, visual field impairment and posterior and reversible alterations on imaging scans(1,2). The clinical picture develops over a few hours, presenting with rapidly progressive neurological symptoms(3). It was first described in 1996. It is more frequent in patients with acute kidney injury or chronic kidney disease, thus in lupus patients with kidney disorders. It is associated with hypertension, other autoimmune diseases beside lupus, immunosuppressive therapies, especially antibody-based immunosuppressive therapy, and organ transplantation. It is clinically reversible within one week and imaging changes resolve within 2-4 weeks. It is treatable and has a good prognosis. We present the case of a young woman of 27 years, diagnosed with systemic lupus erythematosus who developed convulsive seizures, headache, visual impairment, being under immunosuppressive therapy with azathioprine. The kidney biopsy revealed class IV lupus nephritis and partial remission of the nephrotic syndrome. The other manifestations of SLE in this patient were cutaneous, immunological, articular and haematological. The patient had a good short, medium and long-term prognosis at 30 days and also at 6 months.

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Abstract WP220: Can’t Breathe, Can’t See, Can’t Think: Chronic Obstructive Pulmonary Disease Increases the Risk of Posterior Reversible Encephalopathy Syndrome

Stroke ◽

10.1161/str.51.suppl_1.wp220 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Molly Bates ◽

Kyle Darpel ◽

Nneka Amadife ◽

Adam Dugan ◽

Jessica D Lee

Keyword(s):

Blood Pressure ◽

Logistic Regression ◽

Endothelial Dysfunction ◽

Posterior Reversible Encephalopathy Syndrome ◽

Hypertensive Emergency ◽

Categorical Variables ◽

Multivariate Logistic Regression ◽

P Values ◽

Posterior Reversible Encephalopathy ◽

Reversible Encephalopathy

Introduction: Several theories exist regarding the pathogenesis of posterior reversible encephalopathy syndrome (PRES). One theory suggests that PRES occurs when systemic blood pressure exceeds the upper limit of cerebral autoregulation. Endothelial dysfunction has been proposed as an alternative pathogenesis to account for PRES outside the setting of acute hypertension. This mechanism has been implicated in other conditions associated with PRES including autoimmune diseases, cytotoxic medications, sepsis, and eclampsia. The purpose of this study was to determine if COPD, a disease known to cause endothelial dysfunction, has a causative association with the development of PRES. Methods: A single center retrospective, age-matched, case-control study was performed from January 2013 to June 2019 comparing patients discharged with a primary diagnosis of PRES to a control group with acute ischemic stroke. Demographics, medical comorbidities, initial blood pressure, and clinical outcomes were compared between the two groups. For categorical variables, p-values were calculated using χ2 and Fisher’s exact tests. For continuous variables, p-values were calculated using two-sample t-tests. The effect of COPD and acute hypoxic respiratory failure on PRES status was investigated using multivariate logistic regression. Results: A total of 94 PRES subjects and 109 control subjects were included for analysis. Mean age did not differ between the two groups; however, the PRES group was more likely to be female (78.7% vs. 49.5%, p<0.001). COPD was present in 26.6% (n=25) of cases and 11% (n= 12) of controls (odds ratio 4.12, p=0.003). Occurrence of hypertension did not differ significantly between the two groups (78.0% vs 86.2%). Among patients with PRES in the setting of COPD (n=25), 60% (n=16) did not meet criteria for hypertensive emergency. Controlling for hypertensive emergency status in a multivariate logistic regression analysis, patients with COPD were 3.21 times more likely to develop PRES (p= 0.004). Conclusions: To our knowledge, very few reports of PRES in the setting of COPD have been described in the literature and no association of PRES and COPD has been defined to date. Our data support the role of COPD as a risk factor in the development of PRES.

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Posterior reversible encephalopathy syndrome associated with the use of chemotherapeutic agents: a rare complication after treatment with vinorelbine

BMJ Case Reports ◽

10.1136/bcr-2019-229319 ◽

2020 ◽

Vol 13 (2) ◽

pp. e229319 ◽

Cited By ~ 1

Author(s):

Ines Gil ◽

Filipa Serrazina ◽

Miguel Pinto ◽

Miguel Viana-Baptista

Keyword(s):

Blood Pressure ◽

Posterior Reversible Encephalopathy Syndrome ◽

Grey Matter ◽

Rare Complication ◽

Chemotherapeutic Agents ◽

Posterior Reversible Encephalopathy ◽

Parietal Lobes ◽

Reversible Encephalopathy ◽

Visual Disturbances

The posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterised by a combination of headache, encephalopathy, seizures and visual disturbances, associated with high-intensity abnormalities on T2-weighted images affecting subcortical white and grey matter of the occipital and parietal lobes. Among other causes, PRES has been associated with the use of several medications including chemotherapeutic agents. Here we report a case of a 65-year-old patient with squamous cell carcinoma of the lung treated with cisplatin/vinorelbine. Following the second administration of vinorelbine, she was admitted to the hospital for a generalised seizure. Blood pressure was just slightly elevated and, except for drowsiness, she had a near-normal neurological examination. MRI corroborated the diagnosis. Vinorelbine-induced PRES has been reported only once in the literature, also in association with cisplatin. Our case underlines the role of vinorelbine and suggests that its association with cisplatin in this setting may enhance the risk of PRES.

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MRI characteristics of brain edema in preeclampsia/eclampsia patients with posterior reversible encephalopathy syndrome

BMC Pregnancy and Childbirth ◽

10.1186/s12884-021-04145-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Hui Mai ◽

Zhiyu Liang ◽

Zhanhang Chen ◽

Zhaoran Liu ◽

Yaxi Xu ◽

...

Keyword(s):

Blood Pressure ◽

Retrospective Study ◽

Brain Edema ◽

Posterior Reversible Encephalopathy Syndrome ◽

Blood Cell Count ◽

Posterior Reversible Encephalopathy ◽

Potential Predictor ◽

Cranial Mri ◽

Mri Characteristics ◽

Reversible Encephalopathy

Abstract Background The neuroimaging manifestations of eclampsia and preeclampsia often overlap, mainly presenting as posterior reversible encephalopathy syndrome (PRES). The purpose of this retrospective study was to compare the extent and nature of brain edema in eclampsia and preeclampsia patients with PRES based on MRI characteristics. Methods One hundred fifty women diagnosed with preeclampsia-eclampsia and undergoing cranial MRI were enrolled; 24 of these were diagnosed as having eclampsia. According to clinicoradiologic diagnosis of PRES, eligible patients were classified as having eclampsia with PRES (group E-PRES) and preeclampsia with PRES (group P-PRES). A scale on T2W FLAIR-SPIR images was established to evaluate the extent of brain edema, and the score of brain edema (SBE) of both groups was compared. In patients of the two groups who also underwent DWI sequence, the presence or absence of hyperintensity on DWI and hypointensity on ADC maps were determined to compare the nature of brain edema. Furthermore, clinical and biochemical data of the two groups were compared. Results The incidence of PRES in eclampsia patients was significantly higher than that in preeclampsia patients (87.50% vs. 46.03%, P<0.001). The SBE of all regions and typical regions in group E-PRES patients were significantly higher than those in group P-PRES patients (15.88±8.72 vs. 10.90±10.21, P=0.021; 8.52±3.87 vs. 5.01±4.19, P=0.002; respectively). The presence of hyperintensity on DWI was determined more frequently in group E-PRES patients than group P-PRES patients (71.43% vs. 32.00%, P=0.024). Age, systolic blood pressure, white blood cell count, neutrophil count and percentage of neutrophils were significantly different between the two groups (P<0.05). Conclusions Certain MRI characteristics that reflect the extent and nature of brain edema were different between eclampsia and preeclampsia patients with PRES. Additional prospective studies are still required to explore whether these MRI characteristics of brain edema may further become a potential predictor for eclamptic seizures in preeclampsia patients with PRES.

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Posterior Reversible Encephalopathy Syndrome after Heart Transplantation: Diagnosis and Immunosuppressive Therapy

Texas Heart Institute Journal ◽

10.14503/thij-15-5007 ◽

2017 ◽

Vol 44 (3) ◽

pp. 205-208 ◽

Cited By ~ 2

Author(s):

Aniruddh Kapoor ◽

Emma Birks ◽

Andrew Lenneman ◽

Kelly McCants

Keyword(s):

Adverse Effects ◽

Acute Rejection ◽

Heart Transplantation ◽

Immunosuppressive Therapy ◽

Posterior Reversible Encephalopathy Syndrome ◽

Orthotopic Heart Transplantation ◽

Mental Function ◽

Posterior Reversible Encephalopathy ◽

Reversible Encephalopathy ◽

Visual Disturbances

Posterior reversible encephalopathy syndrome, an infrequent neurotoxicity associated with the use of tacrolimus, was first described in 1996, as a reversible syndrome manifested by headache, altered mental function, seizures, and visual disturbances. We describe the case of a 37-year-old woman who developed neurologic symptoms consistent with encephalopathy after treatment with tacrolimus, which was prescribed to maintain immunosuppression after orthotopic heart transplantation. This report also discusses the imaging methods used in the diagnosis of posterior reversible encephalopathy and highlights the difficulty of maintaining immunosuppression and managing medication-related adverse effects, while taking into account the risk of acute rejection after transplantation.

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