A case of posterior reversible encephalopathy syndrome associated with acute pancreatitis and chronic alcoholism

Posterior Reversible Encephalopathy Syndrome in the Setting of Asparaginase-associated Pancreatitis in 2 Pediatric Patients With Acute Leukemia

Asparaginase, a critical component of current pediatric acute leukemia treatment protocols, is associated with a number of serious side effects, one of which is pancreatitis. Pancreatitis can result in significant morbidity and mortality from necrosis, pseudocyst formation, hemorrhage, systemic inflammation, intestinal perforation, and sepsis. Another rare complication of pancreatitis is posterior reversible encephalopathy syndrome, likely mediated by systemic inflammation secondary to pancreatic autodigestion and proinflammatory cytokine-mediated vascular endothelial damage. Here, we review this association in the literature and report 2 pediatric patients with leukemia who developed posterior reversible encephalopathy syndrome in the setting of asparaginase-associated pancreatitis.

Posterior reversible encephalopathy syndrome in acute pancreatitis: a rare stroke mimic

We report a 71-year-old woman who presented with Posterior Reversible Encephalopathy Syndrome (PRES) in the setting of acute pancreatitis. On day 3 of her admission, she developed transient right-sided upper and lower limb weakness, reduced visual acuity and encephalopathy, initially regarded as an acute stroke. Brain MRI fluid-attenuated inversion recovery (FLAIR) T2 imaging performed the same day confirmed occipital and parietal hyperdensities consistent with PRES. Her blood pressure never exceeded 150/75 mm Hg throughout the course of the admission. Our case demonstrates PRES in the setting of acute pancreatitis with only a relatively moderate elevation in blood pressure. In order to prevent unnecessary intervention in the setting of presumed acute stroke, it is important to consider the potential differential diagnoses including PRES as rare masquerade of acute stroke or transient ischaemic attack.

Posterior Reversible Encephalopathy Syndrome in Clinical Toxicology: A Systematic Review of Published Case Reports

Background: Posterior reversible encephalopathy syndrome (PRES) is a rare clinical and radiological entity characterized by a typical brain edema. Although several case reports have described PRES in a context of poisoning, to our knowledge, a comprehensive assessment has not been performed. The aim of this systematic review was to raise awareness on poisoning-specific PRES features and to encourage consistent and detailed reporting of substance abuse–and drug overdose–associated PRES.

Methods: Medline/PubMed, Web of Science, and PsycINFO were screened through May 31, 2019, to systematically identify case reports and case series describing PRES associated with poisoning (i.e., alcohol, drugs, illicit drugs, natural toxins, chemical substances) in accidental context, intentional overdose, and substance abuse. The methodological quality of eligible case reports/series was assessed. Patients and exposure characteristics were recorded; relevant toxicological, radiological, and clinical data were extracted.

Results: Forty-one case reports and one case series reporting 42 unique cases were included. The median time to PRES onset from the start of exposure was 3 days (IQR 2–10). Acute high blood pressure, visual disturbance, and seizure were reported in 70, 55, and 50% of patients, respectively. The initial clinical presentation was alertness disorders in 64% of patients. Nine patients (21%) required mechanical ventilation. One-third of patients had at least one risk factor for PRES such as chronic hypertension (17%) or acute/chronic kidney failure (24%). The main imaging pattern (67%) was the combination of classical parieto-occipital edema with another anatomical region (e.g., frontal, basal ganglia, posterior fossa involvement). Vasogenic edema was found in 86% of patients. Intracranial hemorrhage occurred in 14% of patients. Both brain infarction and reversible cerebral vasoconstriction syndrome were diagnosed in 5% of patients. Three patients (12%, 3/25) had non-reversible lesions on follow-up magnetic resonance imaging. The median time required to hospital discharge was 14 days (IQR 7–18). Mortality and neurological recurrence rate were null.

Conclusions: Comorbidities such as chronic hypertension and kidney failure were less frequent than in patients with other PRES etiologies. Imaging analysis did not highlight a specific pattern for poisoning-induced PRES. Although less described, PRES in the context of poisoning, which shares most of the clinical and radiological characteristics of other etiologies, is not to be ignored.

Arginine Vasopressin and Posterior Reversible Encephalopathy Syndrome Pathophysiology: the Missing Link?

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological entity characterized by a typical brain edema. Its pathogenesis is still debated through hypoperfusion and hyperperfusion theories, which have many limitations. As PRES occurs almost exclusively in clinical situations with arginine vasopressin (AVP) hypersecretion, such as eclampsia and sepsis, we hypothesize that AVP plays a central pathophysiologic role. In this review, we discuss the genesis of PRES and its symptoms through this novel approach. We theorize that AVP axis stimulation precipitates PRES development through an increase in AVP secretion or AVP receptor density. Activation of vasopressin V_1a receptors leads to cerebral vasoconstriction, causing endothelial dysfunction and cerebral ischemia. This promotes cytotoxic edema through hydromineral transglial flux dysfunction and may increase endothelial permeability, leading to subsequent vasogenic brain edema. If our hypothesis is confirmed, it opens new perspectives for better patient monitoring and therapies targeting the AVP axis in PRES.

Naloxone for treatment of patients with acute alcoholism: Efficacy and effect on inflammatory cytokines in gastric mucosa

AIM

To evaluate the clinical effect of naloxone in patients with acute alcoholism and its effect on inflammatory factors in the gastric mucosa.

METHODS

One hundred and fifty patients with acute alcoholism were randomly divided into two groups: a Xingnaojing group (n = 75 cases) and a naloxone group (n = 75 cases). Both groups were given oxygen inhalation, gastric lavage, and gastric mucosa protecting drugs. The Xingnaojing group was additionally given Xingnaojing treatment, and the naloxone group was given naloxone treatment. Time to awakening, time to symptom disappearance, emergency observation time, time to recovery of limb motor function, and hospital stay were recorded. The levels of tumor necrosis factor α (TNF-α) and interleukin-8 (IL-8) in the gastric mucosa at different time points were measured by enzyme-linked immunosorbent assay (ELISA). Clinical efficacy and inflammatory cytokines in the gastric mucosa were compared between the two groups.

RESULTS

Time to awakening, time to symptom disappearance, emergency observation time, time to recovery of limb motor function, and hospital stay were significantly shorter in the naloxone group than in the Xingnaojing group (P < 0.05). The levels of TNF-α and IL-8 in the naloxone group at 1, 2, and 3 d were significantly lower than those in the Xingnaojing group (P < 0.05). The score of Glasgow coma scale was also significantly lower in the naloxone group than in the Xingnaojing group (P < 0.05). The incidence of adverse reactions in the naloxone group was 12.00%, which was significantly lower than that of the Xingnaojing group (26.67%, P < 0.05).

CONCLUSION

Naloxone can shorten the time to improvement of symptoms and reduce the inflammatory cytokines in patients with acute alcoholism.

Posterior Reversible Encephalopathy Syndrome Complicating Traumatic Pancreatitis: A Pediatric Case Report

We are reporting a case of posterior reversible encephalopathy syndrome (PRES) developed in an unusual clinical scenario without the presence of the most described symptoms. PRES is a neurological and radiological syndrome described in many different clinical conditions. In children it has been mostly reported in association with hematological and renal disorders.Our patient was a 15 years old boy, admitted to our intensive care unit for pancreatitis after blunt abdominal trauma.During the stay in the intensive care unit, he underwent multiple abdominal surgical interventions for pancreatitis complications. He had a difficult management of analgesia and sedation, being often agitated with high arterial pressure, and he developed a bacterial peritonitis. After 29 days his neurological conditions abruptly worsened with neuroimaging findings consistent with PRES. His clinical conditions progressively improved after sedation and arterial pressure control.He was discharged at home with complete resolution of the neurological and imaging signs 2 months later.The pathophysiology of PRES is controversial and involves disordered autoregulation ascribable to hypertension and endothelial dysfunction. In this case both hypertension and endothelial activation, triggered by sepsis and pancreatitis, could represent the culprits of PRES onset. Even if there is no specific treatment for this condition, a diagnosis is mandatory to start antihypertensive and supportive treatment. We are therefore suggesting to consider PRES in the differential diagnosis of a neurological deterioration preceded by hypertension and/or septic state, even without other "typical" clinical features.

P38 pathway regulates iNOS and PGE2 expression in hippocampal neurons in rats with severe acute pancreatitis

AIM: To investigate the effect of P38 mitogen-activated protein kinase (P38MAPK) pathway on the expression of inducible nitric oxide synthase (iNOS) and prostaglandin E2 (PGE2) in hippocampal neurons of rats with severe acute pancreatitis (SAP).

METHODS: Healthy male Sprague-Dawley rats were randomly divided into three groups: a control group, a model group, and an SB203580 (an inhibitor of P38MAPK pathway) group. The pathological changes in brain tissue were observed. By immunohistochemistry and Western blot, expression of iNOS and PGE2 and phosphorylation of P38MAPK were detected to observe the changes of positive cell numbers and the expression levels in the hippocampus.

RESULTS: Compared with the control group, the numbers of p-P38 (20.4 ± 2.2 vs 2.1 ± 1.3), iNOS (33.6 ± 4.4 vs 3.7 ± 0.4), and PGE2 (34.7 ± 4.0 vs 2.4 ± 1.0) immunoreactive cells increased markedly in the hippocampal CA1 region (P < 0.05). After treatment with SB203580, the numbers of p-P38 (12.8 ± 0.7), iNOS (14.4 ± 4.9), and PGE2 (18.3 ± 0.5) immunoreactive cells were reduced significantly as compared with the model group (P < 0.05). The inhibitor group had significantly improved pancreatic cell pathology compared to the SAP group, which had ultrastructural changes such as rough endoplasmic network degranulation and mitochondrial swelling expansion.

CONCLUSION: P38MAPK pathway regulates the expression of iNOS and PGE2 in the hippocampus, and inhibition of the pathway has a neuroprotective effect in rats with SAP.

Posterior Reversible Encephalopathy Syndrome (PRES) After Acute Pancreatitis

Posterior reversible encephalopathy syndrome (PRES) is an unusual condition typified by acute visual impairment caused by sudden, marked parieto-occipital vasogenic edema. Thought to be inflammatory in origin, it has been described in patients undergoing chemotherapy, with autoimmune disease, and in some infections. We report a case of PRES that occurred one week after an episode of acute pancreatitis in an otherwise healthy 40-year-old female. There was progressive visual impairment over a 24-hour period with almost complete visual loss, with characteristic findings on magnetic resonance imaging. After treatment with steroids, the visual loss recovered. Clinicians should retain an index of suspicion of this rare condition in patients with visual impairment after acute pancreatitis.