Systemic lupus erythematosus complicated with reversible posterior encephalopathy syndrome: a case report

The challenging clinical dilemma of posterior reversible encephalopathy syndrome in systemic lupus erythematosus

BACKGROUND AND OBJECTIVE

Posterior reversible encephalopathy syndrome (PRES) in systemic lupus erythematosus (SLE) is a challenging clinical dilemma. A retrospective single-center study was performed to investigate the clinical features, risk factors, outcomes, and clinical determinants of the prognosis of PRES in SLE.

METHODS

A retrospective study was performed from January 2015 to December 2020. 19 episodes of lupus PRES and 19 episodes of non-lupus PRES were identified. 38 cases of patients presenting with neuropsychiatric lupus (NPSLE) hospitalized during the same period were selected as controls. Survival status was acquired via outpatient and telephone follow-up in December 2022.

RESULTS

The clinical neurological presentation of PRES in lupus patients was similar to that of the non-SLE-related PRES and NPSLE populations. Nephritis-induced hypertension is the predominant trigger of PRES in SLE. Disease flare and renal failure-triggered PRES were identified in half of the patients with SLE. The mortality rate of lupus-related PRES during the 2‑year follow-up was 15.8%, the same as that of NPSLE. For patients with lupus-related PRES, multivariate analysis indicated that high diastolic blood pressure (OR =1.762, 95% CI: 1.031 ~ 3.012, p = 0.038), renal involvement (OR = 3.456, 95% CI: 0.894 ~ 14.012, p = 0.049), and positive proteinuria (OR = 1.231, 95% CI: 1.003 ~ 1.511, p = 0.047) were independent risk factors compared to NPSLE. A strong connection between the absolute counts of T and/or B cells and prognosis in lupus patients with neurological manifestations was found (p < 0.05). The lower the counts of T and/or B cells, the worse the prognosis.

CONCLUSION

Lupus patients with renal involvement and disease activity are more likely to develop PRES. The mortality rate of lupus-related PRES is similar to that of NPSLE. Focusing on immune balance might reduce mortality.

The Association of Hypertension With Posterior Reversible Encephalopathy Syndrome in Systemic Lupus Erythematosus Patients: A Systematic Review

Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy syndrome (RPLS), is a rare disorder that most commonly affects the posterior part of the brain. Two common causes of PRES are hypertension and autoimmune diseases such as systemic lupus erythematosus (SLE). This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations and aimed at finding the association between hypertension and PRES in SLE patients. We searched medical databases such as PubMed, PubMed Central (PMC), Cochrane Library, and Multidisciplinary Digital Publishing Institute (MDPI) for relevant medical literature. The identified papers were screened, subjected to inclusion and exclusion criteria, and ran through quality appraisal tools, after which 16 papers were finalized. The finalized papers explored the roles of hypertension in SLE patients diagnosed with PRES. In this review, we identified a link between hypertension and PRES-SLE patients. We aimed to explain the role of hypertension in the development of PRES in SLE patients. This study also explains the different treatment modalities to be used for treating the patients presenting with PRES and differentiates other neuropsychiatric illnesses commonly present in SLE patients from PRES. It's important to make an accurate clinical diagnosis by understanding the clinical features and neuroimaging results of PRES for future care since it may even be incurable in some circumstances.

Case Report: Real NPSLE? A patient with systemic sclerosis overlapping systemic lupus erythematosus presenting as epilepsy

Neuropsychiatric systemic lupus erythematosus (NPSLE) is the diagnosis that rheumatologists most often need to consider when a patient with lupus presents with neurologic symptoms. However, neurological involvement is rare in systemic sclerosis (SSc), and high doses of steroids tend to trigger scleroderma renal crisis (SRC). When a patient with SSc overlapping SLE presents with epilepsy and renal crisis, the exact diagnosis and whether to initiate high-dose glucocorticoid therapy are questions to ponder. Here, we report a patient with overlap syndrome (SSc overlapping SLE), who developed CNS symptoms, and improved after treatment against SRC after excluding NPSLE. We report this case with the aim of arousing the attention of rheumatologists to SSc and SRC-related encephalopathy when SSc was overlapped with SLE.