Posterior Reversible Encephalopathy Syndrome Complicating Ruptured Appendicitis and Abscess Drainage in a Previously Healthy Pediatric Patient

Posterior reversible encephalopathy syndrome following appendicitis in a young child: A case report and review of the pediatric literature

Posterior reversible encephalopathy syndrome is an acute or subacute neurological disorder with variable clinical manifestations including encephalopathy, headache, seizures, visual disturbance, and focal neurologic deficits. Neuroimaging often shows frequently reversible vasogenic edema that predominantly involves the subcortical parieto-occipital lobes. Posterior reversible encephalopathy syndrome has been associated with hypertension and reported in patients with many conditions including eclampsia/pre-eclampsia and immunosuppressive therapy. Recently, posterior reversible encephalopathy syndrome is recognized to occur in association with severe infections such as complicated appendicitis. Here, we describe a case of 11-year-old male admitted for complicated appendicitis and severe sepsis. He developed seizures and had an altered mental status 10 days into his hospitalization with brain magnetic resonance imaging findings consistent with posterior reversible encephalopathy syndrome. We review the pediatric literature and discuss the pathogenesis of posterior reversible encephalopathy syndrome in association with an infection. We highlight the importance of recognizing this syndrome as a possible cause for acute neurological deterioration in children with severe infections.

Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients

The posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.