Positive Effect of Steroids in Posterior Reversible Encephalopathy Syndrome

COVID-19-related posterior reversible encephalopathy syndrome: insights from a clinical case

In the present case report, a 50-year-old female presented with hemiparesis and blurred vision and was subsequently diagnosed with posterior reversible encephalopathy syndrome (PRES) associated with coronavirus disease 2019 (COVID-19). Magnetic resonance imaging revealed cortico-subcortical edema with hyperintensities bilaterally in the frontoparietal and bi-occipital regions. Although PRES is a neurotoxic disorder that typically affects white matter of the brain and often is associated with hypertension, renal failure, and autoimmune disorders, recent studies have suggested that COVID-19 increases the risk of PRES. This case report presents a unique instance of COVID-19-related PRES. Unlike most previously reported cases occurring during the acute phase of severe COVID-19, our patient experienced PRES during the recovery phase with mild initial symptoms, such as fatigue and mild fever. The article discusses the pathophysiology of PRES, the potential mechanisms by which COVID-19 leads to PRES, and the treatment and outcome of the patient.

[Posterior reversible encephalopathy syndrome in autoimmune disorders]

Posterior reversible encephalopathy syndrome (PRES) is characterized by nonspecific symptoms, including not only pronounced non-focal and various focal neurological signs but also specific neuroimaging features, including vasogenic edema affecting predominantly the posterior area. PRES usually develops in the setting of acute arterial hypertension. However, it is not uncommon for PRES to develop in non-hypertensive patients, including people with autoimmune disorders (multiple sclerosis, neuromyelitis optica spectrum disorder, etc). PRES could also be due to the toxic effects of drugs or other substances. The pathophysiological mechanisms of PRES include impaired autoregulation of cerebral blood flow due to acute arterial hypertension and toxic endotheliotropic effects of endogenous and exogenous factors.

Posterior reversible encephalopathy syndrome - A pathology that should not be overlooked in the era of COVID-19

BACKGROUND AND OBJECTIVES

Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) that causes Coronavirus Disease 2019 (COVID-19) may determine a series of neurological complications directly, by invasion of the nervous system or indirectly, secondary to systemic organ failure. Posterior reversible encephalopathy syndrome (PRES) represents a clinical and radiological neurological entity involving predominantly the occipital lobes. PRES was observed in patients receiving cytotoxic drugs, patients suffering from infectious diseases and sepsis, hypertensive emergencies and eclampsia, renal or autoimmune diseases. As more infectious SARS-COV-2 variants are now dominant in most of the Europe, an increasing number of patients is presenting to the Emergency Department.

MATERIALS AND METHODS

Case report of a 38-year-old patient, with previous exposure to SARS-COV-2 presented to the Emergency Department (ED) with generalized tonic-clonic seizures, dyspnea, cortical blindness and aphasia. The patient had been exhibiting fever, cough and shortness of breath in the previous 10 days. He had no relevant medical history and was receiving antibiotics and corticosteroids as prescribed by his general practitioner.

RESULTS

Laboratory findings together with the thoracic computed tomography scan were consistent with the diagnosis of severe SARS-COV-2 pneumonia. The cerebral MRI scans showed bilateral T2-weighted/FLAIR hyperintensities that were suggestive for PRES. The patient was diagnosed with COVID-19 complicated with PRES. He received adequate treatment and the symptoms resolved in 48 h.

CONCLUSIONS

This is a rare and interesting case of a patient with PRES and COVID-19 as underlying pathology, in whom rapid diagnosis in the ED and early initiation of appropriate treatment led to full recovery. Immediate extensive work-up in patients with COVID-19 and neurological symptoms proves to be paramount for best outcome. To our knowledge this is the first case of PRES described in a patient with Delta variant of SARS-COV-2.

Rapid clinical recovery of posterior reversible encephalopathy syndrome in two cases of IgA nephropathy disease and nephrotic syndrome type 9 post-renal transplant

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological syndrome often associated with immunosuppressant drug use, renal disease, and eclampsia and characterized by parieto-occipital vasogenic edema that usually resolves within days. Globally and in the settings of renal transplant, literature concerning PRES is very scattered. In this report, we provide two cases, one diagnosed with IgA nephropathy and another with nephrotic syndrome type 9 that developed episodes of tonic-clonic seizure immediately after renal transplant in case 1 and four days post-transplant in case 2. The two patients had a history of hypertension, renal disease, corticosteroid and immunosuppressant drug use. Neuro-imaging showed typical vasogenic edema involving the parieto-occipital areas. Therefore, the clinical-radiological presentation confirmed the diagnosis of PRES in both cases. Also, rapid neurologic recovery was witnessed upon administration of anti-epileptic and anti-hypertensive medications. Non-discontinuation of immunosuppressants, steroids, early symptomatic management, and blood pressure control are favorable factors that might explain the rapid recovery of these two patients.

Posterior reversible encephalopathy syndrome following Miller-Fisher syndrome

A 71-year-old woman presented to the emergency room with dysphonia, diplopia, dysphagia and generalised weakness since that day. Neurological examination revealed eye adduction limitation, ptosis, hypoactive reflexes and gait ataxia. Blood and cerebrospinal fluid analysis and brain CT were normal. Electromyography revealed a sensory axonal polyneuropathy. She was diagnosed with Miller-Fisher syndrome (MFS) and started on intravenous immunoglobulin. Two days after intravenous immunoglobulin treatment was completed, she developed a sustained hypertensive profile and presented a generalised tonic-clonic seizure. Brain MRI was suggestive of posterior reversible encephalopathy syndrome (PRES) and supportive treatment was implemented with progressive improvement. PRES may be a possible complication of MFS not only due to autonomic and inflammatory dysfunctions, but also as a consequence of its treatment. Patients with MFS should be maintained under close surveillance, especially in the first days and preferably in intermediate care units.

Posterior Reversible Encephalopathy Syndrome After Azathioprine Administration in Severe Ulcerative Colitis

Posterior reversible encephalopathy syndrome is a rare syndrome characterized by brain edema and neurological symptoms, often resulting from several drugs. Treatment is based on discontinuation, and diagnosis is thus essential. Only 13 cases of posterior reversible encephalopathy syndrome have been reported in inflammatory bowel diseases, and we present the first after azathioprine in adults. A 56-year-old patient with active ulcerative colitis was found unconscious 5 days after the institution of azathioprine. Right-sided hemiplegia was found after the patient regained consciousness. Magnetic resonance imaging showed altered signal associated with diffusion restriction in the occipital lobe and cerebral vasogenic edema. Complete regression of neurological signs occurred after azathioprine discontinuation.

Posterior Reversible Encephalopathy Syndrome After Transsphenoidal Resection of Pituitary Macroadenoma

BACKGROUND

Posterior reversible encephalopathy syndrome is manifested by a reversible neurologic deficit such as vision loss, encephalopathy, and a posterior location, typically the occipital lobes. It is commonly thought to be related to acute, severe hypertension.

CASE DESCRIPTION

A 51-year-old woman presented with visual loss for several months, and a suprasellar mass was diagnosed. She underwent transsphenoidal surgery, which was complicated by cerebrospinal fluid leak, and she developed posterior reversible encephalopathy syndrome while undergoing postoperative cerebrospinal fluid drainage via lumbar catheter. Her visual acuity progressed to blindness, but blindness was reversed by discontinuation of lumbar drainage, tight blood pressure control, and high-dose steroid drip.

CONCLUSIONS

To our knowledge, this is only the second case of posterior reversible encephalopathy syndrome following transsphenoidal surgery to be reported in the neurosurgical or ophthalmic English language literature.