Posterior reversible encephalopathy syndrome in malignant hypertension secondary to focal segmental glomerulosclerosis

Drugs associated with posterior reversible encephalopathy syndrome, a worldwide signal detection study

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) can occur in a variety of clinical conditions, such as severe hypertension, pregnancy, inflammatory diseases, hematopoietic stem cells or solid organ transplantation. Apart increased blood pressure levels and altered renal function, several drugs have been reported as potential triggering factor. These descriptions are nevertheless limited to case reports or small case series. Systematic analysis of drugs associated with PRES using global pharmacovigilance database is lacking and can be useful.

METHODS

We performed a disproportionality analysis using VigiBase, the World Health Organization pharmacovigilance database, using the information component (IC). The IC compares observed and expected values to find associations between drugs and PRES using disproportionate Bayesian reporting. An IC_0.25 (lower end of the IC 95% credibility interval) > 0 is considered statistically significant.

RESULTS

Here we present an analysis of 3278 cases of PRES reported in VigiBase. These results identified 73 molecules statistically associated with PRES using full database as background with an IC_0.25 > 0. Only 34% (N = 25/73) of them had this information written in the summary of product characteristics. The main drug classes involved were antineoplastic and immunomodulating agents and the drugs with the greatest number of cases were tacrolimus, cyclosporin, bevacizumab, methotrexate, and vincristine. An overall mortality of 8.1% (N = 267/3278) was identified in cases of drug-associated PRES.

CONCLUSION

These results will help clinicians identify potential suspected drugs associated with PRES and decide which drug to discontinue and eventually lead to a re-evaluation of drug labels for some molecules.

Posterior Reversible Encephalopathy Syndrome (PRES) in a Patient With Primary Myelofibrosis on Ruxolitinib

Posterior reversible encephalopathy syndrome (PRES) is a reversible neurological syndrome characterized by headache, seizures, altered mental status, and visual abnormalities, in association with the characteristic bilateral white matter abnormalities in the posterior cerebral hemispheres. As the name suggests, it is typically reversible with clinical recovery within a few days, while the magnetic resonance imaging (MRI) abnormalities resolve much more slowly. We present a 78-year-old female with a known diagnosis of primary myelofibrosis (PMF), on ruxolitinib, a Janus kinase (JAK) 1 and 2 inhibitor, presenting with altered mental status. On presentation, she was hypertensive and with possible sepsis, secondary to urinary tract infection (UTI). She was intubated because of her low Glasgow Coma Scale (GCS), to secure her airways. Computed tomography (CT) of the brain did not reveal any acute ischemic changes. MRI of the brain exhibited findings suggestive of PRES. Ruxolitinib was held and the patient was treated with antihypertensives, anticonvulsants, and antibiotics. Within 24 hours of hospitalization, the patient had a complete neurological recovery, which is diagnostic of PRES. She was extubated successfully and was discharged with a resolution of her symptoms. Although several chemotherapeutic and immunosuppressant drugs are reported to be associated with PRES, the association between ruxolitinib and PRES has not been well established. Thus, case reporting is important to highlight the possible association between ruxolitinib and PRES.

Posterior reversible encephalopathy syndrome associated with focal segmental glomerulosclerosis in a child

Posterior reversible encephalopathy syndrome (PRES) is a rare neurological entity, typically manifested by reversible oedema in the parieto-occipital lobes. It is usually associated with primary hypertension, autoimmune diseases and immunosuppressants. Renal disease is an uncommon cause of PRES. We report a case of an 11-year-old boy with STimulator of INterferon Genes-associated vasculopathy with onset in infancy complicated by focal segmental glomerulosclerosis leading to hypertension and PRES. The patient presented with headache, acute bilateral visual loss and hypertension. Brain MRI showed atypical features revealed by parieto-occipital haemorrhage. The child improved few days after antihypertensive therapy. Follow-up MRI showed complete resolution of haemorrhage. It is important to keep high index of suspicion for the uncommon association of PRES with underlying kidney disease with or without immunosuppressive agents. This combination is the first to our knowledge to be described in paediatric population. Atypical MRI features such as haemorrhage should be kept in mind. Symptoms are reversible within days to weeks with early diagnosis and treatment.