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Nikolaidou A, Beis I, Dragoumi P, Zafeiriou D. Neuropsychiatric manifestations associated with Juvenile Systemic Lupus Erythematosus: An overview focusing on early diagnosis. Brain Dev 2024; 46:125-134. [PMID: 38061949 DOI: 10.1016/j.braindev.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/18/2023] [Accepted: 11/27/2023] [Indexed: 02/17/2024]
Abstract
Juvenile systemic lupus erythematosus (jSLE) is a chronic multisystem inflammatory disease that manifests before the age of 16 years, following a remitting - relapsing course. The clinical presentation in children is multifaceted, most commonly including constitutional, hematological, cutaneous, renal, and neuropsychiatric symptoms. Neuropsychiatric manifestations range widely, affecting approximately 14-95 % of jSLE patients. They are associated with high morbidity and mortality, particularly at a younger age. Headaches, seizures, cognitive dysfunction, and mood disorders are the most frequent neuropsychiatric manifestations. The pathophysiological mechanism is quite complex and has not yet been fully investigated, with autoantibodies being the focus of research. The diagnosis of neuropsychiatric jSLE remains challenging and exclusionary. In this article we review the clinical neuropsychiatric manifestations associated with jSLE with the aim that early diagnosis and prompt treatment is achieved in children and adolescents with the disease.
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Affiliation(s)
- Anna Nikolaidou
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Ioannis Beis
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
| | - Dimitrios Zafeiriou
- 1st Department of Pediatrics, «Hippokratio» General Hospital, Aristotle University, Thessaloniki, Greece
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Posterior reversible encephalopathy syndrome in children with kidney disease. Int Urol Nephrol 2017; 49:1793-1800. [DOI: 10.1007/s11255-017-1684-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 08/17/2017] [Indexed: 01/13/2023]
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Veloso P, Freitas D, Reis A, Prado S, Montandon A, Silva N, Rêgo J. SÍNDROME DE LEUCOENCEFALOPATIA POSTERIOR REVERSÍVEL E LÚPUS ERITEMATOSO SISTÊMICO: RELATO DE CASO. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Acute Kidney Injury, Recurrent Seizures, and Thrombocytopenia in a Young Patient with Lupus Nephritis: A Diagnostic Dilemma. Case Rep Nephrol 2016; 2016:7104098. [PMID: 28044115 PMCID: PMC5164895 DOI: 10.1155/2016/7104098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/13/2016] [Indexed: 12/21/2022] Open
Abstract
Introduction. Posterior reversible encephalopathy syndrome (PRES) is a constellation of clinical and radiologic findings. Fluctuations in blood pressure, seizures, and reversible brain MRI findings mainly in posterior cerebral white matter are the main manifestations. PRES has been associated with multiple conditions such as autoimmune disorders, pregnancy, organ transplant, and thrombotic microangiopathy (TMA). Case Presentation. A 22-year-old woman with history of Systemic Lupus Erythematous complicated with chronic kidney disease secondary to lupus nephritis class IV presented with recurrent seizures and uncontrolled hypertension. She was found to have acute kidney injury and thrombocytopenia. Repeat kidney biopsy showed diffuse endocapillary and extracapillary proliferative and membranous lupus nephritis (ISN-RPS class IV-G+V) and endothelial swelling secondary to severe hypertension but no evidence of TMA. Brain MRI showed reversible left frontal and parietal lesions that resolved after controlling the blood pressure, making PRES the diagnosis. Conclusion. PRES is an important entity that must be recognized and treated early due to the potential reversibility in the early stages. Physicians must have high suspicion for these unusual presentations. We present a case where performing kidney biopsy clinched the diagnosis in our patient with multiple confounding factors.
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Ferreira TS, Reis F, Appenzeller S. Posterior reversible encephalopathy syndrome and association with systemic lupus erythematosus. Lupus 2016; 25:1369-1376. [DOI: 10.1177/0961203316643598] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Introduction Posterior reversible encephalopathy syndrome (PRES) is a neurological complex disorder with many clinical associations and causative factors. It is important to recognize this condition because early diagnosis and treatment usually result in its complete resolution, radiological imaging becoming the key for the correct diagnosis. Methods We retrospectively reviewed charts and magnetic resonance imaging findings in the University of Campinas from January 2005 to July 2015, selecting three cases of patients with systemic lupus erythematosus syndrome who developed PRES, for whom risk factors, characteristics, magnetic resonance imaging findings and neurological resolution were analyzed. We also conducted a review of the English-language literature. Results The three cases had neurological symptoms like acute onset of headache, altered mental status, cortical blindness and seizures. Brain magnetic resonance imaging demonstrated posterior cortical and white matter alterations involving posterior brain territories, which were more conspicuous on T2-weighted and fluid-attenuated inversion recovery . Spectroscopy, diffusion-weighted imaging and susceptibility-weighted imaging were also important for neuroradiological evaluation. Immunosuppressive drugs were taken in all cases. Partial clinical and radiological recovery was observed in two cases, and complete resolution was observed in the third patient. Literature review We found 52 cases of PRES in systemic lupus erythematosus patients. Almost all patients were women 94%, ranging from 8 to 62 years old. Posterior brain territory involvements were found in 98% of patients. Hemorrhagic complications involved 26% of patients, becoming a risk factor for clinical sequels. The total percentage of patients with no complete resolution of radiological findings on follow-up images was 27.5%. Discussion In patients with autoimmune disorders, endothelial dysfunction may occur secondary to autoimmunity and the use of cytotoxic drugs, supposedly facilitating the occurrence of more severe PRES. The hypothesis that patients with autoimmune diseases have a propensity to develop non-reversible lesions has been raised.
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Affiliation(s)
- TS Ferreira
- Department of Radiology, University of Campinas, Campinas, Brazil
| | - F Reis
- Department of Radiology, University of Campinas, Campinas, Brazil
| | - S Appenzeller
- Department of Clinics, University of Campinas, Campinas, Brazil
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Nasri A, Bedoui I, Mrissa R, Riahi A, Derbali H, Zaouali J, Messelmani M, Mansour M. Recurrent status epilepticus in posterior reversible encephalopathy syndrome as initial feature of pediatric lupus: A newly diagnosed case and literature review. Brain Dev 2016; 38:835-41. [PMID: 27068876 DOI: 10.1016/j.braindev.2016.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/25/2016] [Accepted: 03/28/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Posterior reversible encephalopathy syndrome (PRES) is a recently described clinico-neuroradiological syndrome with several predisposing conditions. Systemic lupus erythematosus (SLE), beginning in 15-20% in childhood, is considered as a potential underlying etiology of PRES. In children, status epilepticus (SE) rarely complicates PRES, and exceptionally occurs in SLE. METHODS We report on an illustrative case of PRES complicating pediatric lupus revealed by recurrent SE, and we further review through a Pubmed search the previously reported cases of pediatric SLE, PRES and SE. RESULTS We describe the case of a 12-year old girl who presented with recurrent status epilepticus associated to high blood pressure and renal involvement. Brain imaging showed classical aspects of PRES. Immunological tests including antinuclear, anti-DNA, and anticardiolipin antibodies were positive. The diagnosis of SLE was established. The Pubmed search identified a total number of 9 children with SE in SLE, and 26 with PRES, including our patient. CONCLUSIONS We discussed the clinical and paraclinical features of PRES in SLE with epilepsy, their underlying pathophysiological aspects, and their management challenges. PRES should be considered in initial recurrent SE in children, justifying a battery of tests comprising immunological testing. Anticardiolipin antibodies seem to play a crucial role in epilepsy, PRES and renal involvement in pediatric SLE. Further studies are needed to clarify whether PRES should be considered one of the neuropsychiatric manifestations of SLE or a consequence of active disease in other organ systems or its treatment.
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Affiliation(s)
- Amina Nasri
- Department of Neurology, Military Hospital, Tunisia.
| | - Ines Bedoui
- Department of Neurology, Military Hospital, Tunisia
| | - Ridha Mrissa
- Department of Neurology, Military Hospital, Tunisia
| | - Anis Riahi
- Department of Neurology, Military Hospital, Tunisia
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Fujieda Y, Kataoka H, Odani T, Otomo K, Kato M, Fukaya S, Oku K, Horita T, Yasuda S, Atsumi T, Koike T. Clinical features of reversible posterior leukoencephalopathy syndrome in patients with systemic lupus erythematosus. Mod Rheumatol 2014. [DOI: 10.3109/s10165-010-0386-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Yuichiro Fujieda
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Hiroshi Kataoka
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Toshio Odani
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Kotaro Otomo
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Masaru Kato
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Shinji Fukaya
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Kenji Oku
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Tetsuya Horita
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Shinsuke Yasuda
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Tatsuya Atsumi
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
| | - Takao Koike
- Department of Medicine II, Hokkaido University Graduate School of Medicine,
N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan
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Lai CC, Chen WS, Chang YS, Wang SH, Huang CJ, Guo WY, Yang WC, Huang DF. Clinical Features and Outcomes of Posterior Reversible Encephalopathy Syndrome in Patients With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2013; 65:1766-74. [DOI: 10.1002/acr.22047] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 04/25/2013] [Accepted: 05/01/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Chien-Chih Lai
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
| | - Wei-Sheng Chen
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
| | - Yu-Sheng Chang
- Shuang Ho Hospital, Taipei Medical University, New Taipei City, and National Yang-Ming University; Taipei Taiwan
| | - Shu-Hung Wang
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
| | - Chun-Jui Huang
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
| | - Wan-Yuo Guo
- Taipei Veterans General Hospital; Taipei Taiwan
| | | | - De-Feng Huang
- Taipei Veterans General Hospital, Taiwan and National Yang-Ming University; Taipei Taiwan
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Abstract
Lupus nephritis is a common complication of systemic lupus erythematosus in children and adolescents. This article reviews the clinical relevance of lupus nephritis and its current treatment. The reader is introduced to novel biomarkers that are expected to improve the management of lupus nephritis in the future, and support the testing of novel medication regimens.
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Affiliation(s)
- Michael Bennett
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, MC 7022, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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Cellucci T, Benseler SM. Posterior reversible encephalopathy syndrome: increasing recognition of an important clinical entity in young patients with systemic lupus erythematosus. J Rheumatol 2012; 38:1544-5. [PMID: 21807785 DOI: 10.3899/jrheum.110774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Posterior reversible encephalopathy syndrome in children with kidney diseases. Pediatr Nephrol 2012; 27:375-84. [PMID: 21556718 DOI: 10.1007/s00467-011-1873-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 03/16/2011] [Accepted: 03/16/2011] [Indexed: 10/18/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) was originally used to describe a reversible, predominantly posterior leukoencephalopathy in patients who had renal insufficiency, hypertension, or who received immunosuppressive therapy. Since PRES is prevalent in children with kidney diseases, awareness and understanding of it is important for practicing pediatric nephrologists. A comprehensive approach to the diagnosis of PRES includes thorough determination of predisposing factors, clinical symptoms, and mandatory appropriate imaging. Unfortunately, the pathophysiology of PRES is still obscure and specificity of radiological examination has not yet been established. Two major predisposing factors, namely hypertension and calcineurin inhibitors, are well recognized. In addition, nephrotic syndrome is a common underlying condition for development of PRES. Frequent symptoms include altered consciousness (coma, stupor, lethargy, confusion), seizure, headache, and visual disturbance. Most of these symptoms usually develop abruptly and resolve within a few weeks after proper management. Cranial magnetic resonance (MR) imaging is the first-line modality of imaging studies for detecting PRES. Diffusion-weighted imaging with quantification of apparent diffusion coefficient (ADC) values by ADC mapping may provide more accurate and specific images in the future.
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Abstract
PURPOSE OF REVIEW Extensive systemic illness and treatment with immunosuppressive agents often require patients with rheumatic diseases to be monitored or managed in the pediatric intensive care unit. Additionally, severe disease-specific manifestations of childhood rheumatic disorders present pediatric rheumatologists and critical care physicians with diagnostic and treatment challenges. Although mortality from rheumatic disease in children is rare, the most severe diseases, such as pediatric systemic lupus erythematosus and juvenile dermatomyositis, remain life-threatening. RECENT FINDINGS Advances in therapy have reduced the incidence of severe complications of autoimmune and inflammatory diseases and have expanded treatment options. However, patients with active underlying rheumatic disease and secondary infection who are being treated with immunosuppressive agents are most at risk for poor outcomes. SUMMARY Here we discuss the complications of childhood rheumatic conditions that necessitate critical intervention. We discuss how improved understanding of the cellular and molecular basis of disease pathogenesis holds the promise of more targeted therapy without the adverse effects of global immunosuppression.
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Marrone LCP, Marrone BF, de la Puerta Raya J, Gadonski G, da Costa JC. Gemcitabine monotherapy associated with posterior reversible encephalopathy syndrome. Case Rep Oncol 2011; 4:82-7. [PMID: 21475595 PMCID: PMC3072184 DOI: 10.1159/000324581] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Posterior reversible encephalopathy syndrome is a clinicoradiologic entity that may present with headaches, altered mental status, seizures and visual loss as well as specific neuroimaging findings. We report a case of a 74-year-old woman receiving adjuvant gemcitabine chemotherapy as monotherapy for a stage IIa pancreatic adenocarcinoma, who developed posterior reversible encephalopathy syndrome.
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Abstract
Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, altered mental status, visual disturbances, and seizures. Radiological features typically include edema of the posterior cerebral regions, especially of the parietooccipital lobes. Atypical imaging features, such as involvement of anterior cerebral regions, deep white matter, and the brain stem are also frequently seen. Vasoconstriction is common in vascular imaging. Different conditions have been associated with PRES, but toxemia of pregnancy, solid organ or bone marrow transplantation, immunosuppressive treatment, cancer chemotherapy, autoimmune diseases, and hypertension are most commonly described. The pathophysiology of PRES is unclear and different hypotheses are being discussed. Posterior reversible encephalopathy syndrome is best managed by monitoring and treatment in the setting of a neurointensive care unit. The prognosis is usually benign with complete reversal of clinical symptoms within several days, when adequate treatment is immediately initiated. Treatment of severe hypertension, seizures, and withdrawal of causative agents represent the hallmarks of specific therapy in PRES. Delay in diagnosis and treatment may lead to permanent neurological sequelae. Therefore, awareness of PRES is of crucial importance for the intensivist.
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Affiliation(s)
- Dimitre Staykov
- Neurology Department, University of Erlangen-Nuremberg, Germany.
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Fujieda Y, Kataoka H, Odani T, Otomo K, Kato M, Fukaya S, Oku K, Horita T, Yasuda S, Atsumi T, Koike T. Clinical features of reversible posterior leukoencephalopathy syndrome in patients with systemic lupus erythematosus. Mod Rheumatol 2011; 21:276-81. [PMID: 21225443 DOI: 10.1007/s10165-010-0386-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 11/04/2010] [Indexed: 11/24/2022]
Abstract
To characterize reversible posterior leukoencephalopathy syndrome (RPLS) in systemic lupus erythematosus (SLE) in terms of treatments for resolution and its clinical course, we reviewed 28 cases of RPLS in SLE including our cases in view of the treatment. Of these, 15 cases improved with blood pressure control and 13 required immunosuppressive therapy for activity of SLE presenting neurological manifestations. Patients without immunosuppressants at onset of RPLS more frequently required immunosuppressive therapy to recover it than those precedingly using these agents [31% (4/13) versus 87% (13/15), p = 0.008, chi-square test]. Brain magnetic resonance imaging (MRI) is important for diagnosis of RPLS-SLE in the patient with SLE who develops neurological disturbance and rapidly increasing blood pressure. When 7-day therapy for hypertension and convulsion does not reverse the manifestations, immunosuppressive treatments would be recommended to reverse RPLS.
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Affiliation(s)
- Yuichiro Fujieda
- Department of Medicine II, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo 060-8638, Hokkaido, Japan.
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Children with posterior reversible encephalopathy syndrome associated with atypical diffusion-weighted imaging and apparent diffusion coefficient. Clin Exp Nephrol 2010; 15:275-80. [DOI: 10.1007/s10157-010-0380-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2010] [Accepted: 10/27/2010] [Indexed: 10/18/2022]
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Muscal E, Traipe E, de Guzman MM, Myones BL, Brey RL, Hunter JV. MR imaging findings suggestive of posterior reversible encephalopathy syndrome in adolescents with systemic lupus erythematosus. Pediatr Radiol 2010; 40:1241-5. [PMID: 20119723 DOI: 10.1007/s00247-009-1540-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Revised: 12/04/2009] [Accepted: 12/24/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endothelial damage, hypertension and cytotoxic medications may serve as risk factors for the posterior reversible encephalopathy syndrome (PRES) in systemic lupus erythematosus. There have been few case reports of these findings in pediatric lupus patients. OBJECTIVE We describe clinical and neuroimaging findings in children and adolescents with lupus and a PRES diagnosis. MATERIALS AND METHODS We identified all clinically acquired brain MRIs of lupus patients at a tertiary care pediatric hospital (2002-2008). We reviewed clinical features, conventional MRI and diffusion-weighted imaging (DWI) findings of patients with gray- and white-matter changes suggestive of vasogenic edema and PRES. RESULTS Six pediatric lupus patients presenting with seizures and altered mental status had MRI findings suggestive of PRES. In five children clinical and imaging changes were seen in conjunction with hypertension and active renal disease. MRI abnormalities were diffuse and involved frontal regions in five children. DWI changes reflected increased apparent diffusivity coefficient (unrestricted diffusion in all patients). Clinical and imaging changes significantly improved with antihypertensive and fluid management. CONCLUSION MRI changes suggestive of vasogenic edema and PRES may be seen in children with active lupus and hypertension. The differential diagnosis of seizures and altered mental status should include PRES in children, as it does in adults.
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Affiliation(s)
- Eyal Muscal
- Baylor College of Medicine and Pediatric Rheumatology Center, Texas Children's Hospital, 6621 Fannin St., MC 3-2290, Houston, TX 77030, USA.
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Charuvanij S, Houghton KM. Acute epiglottitis as the initial presentation of pediatric Systemic Lupus Erythematosus. Pediatr Rheumatol Online J 2009; 7:19. [PMID: 19878586 PMCID: PMC2777903 DOI: 10.1186/1546-0096-7-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Accepted: 10/31/2009] [Indexed: 11/10/2022] Open
Abstract
We report a case of a 5-year old girl, who initially presented with acute epiglottitis, sepsis and multi-organ failure. She was subsequently diagnosed as having Systemic Lupus Erythematosus. To the best of our knowledge, this article describes the first case of Haemophilus influenzae type f epiglottitis as the initial presentation of SLE in childhood.
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Affiliation(s)
- Sirirat Charuvanij
- Division of Pediatric Rheumatology, British Columbia's Children's Hospital, Vancouver, Canada.
| | - Kristin M Houghton
- Division of Pediatric Rheumatology, British Columbia's Children's Hospital, Vancouver, Canada,University of British Columbia, Vancouver, Canada
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Abstract
PURPOSE OF REVIEW The ophthalmologist may be called upon to evaluate visual loss in a patient with posterior reversible encephalopathy syndrome. Familiarity with presentation and clinical management is imperative, as visual loss is often reversible with prompt treatment directed at causative factors. RECENT FINDINGS Since its initial description in 1996, the predisposing factors, clinical presentation and radiographic variation of posterior reversible encephalopathy syndrome continue to expand. Case reports of newly uncovered associations of the syndrome appear frequently. Originally considered a subcortical disease of the posterior cerebrum, posterior reversible encephalopathy syndrome has been shown to affect gray matter and can involve both the anterior and posterior cortex, brainstem, cerebellum or even the spinal cord. The pathophysiologic basis of cerebral edema and molecular mechanisms of edema underlying the syndrome are currently being revealed. SUMMARY Acute hypertension, eclampsia, immunosuppressive medication, infection or autoimmune diseases can all result in the clinical syndrome of vasogenic edema in the central nervous system leading to headache, seizure, confusion and frequent visual loss. The biologic basis for the syndrome is likely an insult to cerebral vascular autoregulation. MRI is essential in diagnosing a cerebral cause for visual loss. The ophthalmologist may have the initial opportunity to diagnose the syndrome. Treatment may reverse clinical deficits, and is based on eliminating the etiologic causation.
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Bibliography. Current world literature. Neuro opthalmology. Curr Opin Ophthalmol 2008; 19:541-4. [PMID: 18854700 DOI: 10.1097/icu.0b013e328317c7c4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Rolando Cimaz
- AOU Meyer and University of Florence, Florence, Italy
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Kimura M, Aramaki K, Wada T, Nishi K, Matsushita R, Iizuka N, Hashimoto A, Tanaka S, Ishikawa A, Endo H, Hirohata S. Reversible focal neurological deficits in systemic lupus erythematosus: report of 2 cases and review of the literature. J Neurol Sci 2008; 272:71-6. [PMID: 18538345 DOI: 10.1016/j.jns.2008.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 04/11/2008] [Accepted: 04/22/2008] [Indexed: 11/26/2022]
Abstract
We report two cases presenting focal neurological deficits with high intensity lesions in fluid attenuated inversion recovery (FLAIR) images on brain magnetic resonance imaging (MRI), which almost completely improved by corticosteroid therapy. Marked elevation of cerebrospinal fluid IL-6 was also noted when these patients showed neurological deficits. As far as we explored, there have been thirteen published case reports of systemic lupus erythematosus patients with reversible focal neurological deficits. The neurological symptoms varied from case to case, but could be attributed to the lesions on MRI scans. The completely reversible feature of neurological manifestations as well as MRI findings on corticosteroid therapy is distinct from any other disorder, including cerebrovascular disease and demyelinating syndrome, in the 1999 American College of Rheumatology nomenclature. Therefore, we propose that reversible focal neurological deficits should be added to the 1999 nomenclature and classification and case definitions.
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Affiliation(s)
- Miho Kimura
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa 228-8555, Japan
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Leroux G, Sellam J, Costedoat-Chalumeau N, Le Thi Huong D, Combes A, Tieulié N, Haroche J, Amoura Z, Nieszkowska A, Chastre J, Dormont D, Piette JC. Posterior reversible encephalopathy syndrome during systemic lupus erythematosus: four new cases and review of the literature. Lupus 2008; 17:139-47. [PMID: 18250139 DOI: 10.1177/0961203307085405] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) associates various neurological manifestations (headaches, seizures, altered mental status, cortical blindness, focal neurological deficits, vomiting) and transient changes on neuroimaging consistent with cerebral edema. Posterior reversible encephalopathy syndrome mainly occurs in the setting of hypertension, eclampsia, renal failure and/or use of immunosuppressive drugs. We report four cases of PRES complicating systemic lupus erythematosus (SLE). In all our cases, renal involvement and hypertension were present. Neurological symptoms were typical. Magnetic resonance imaging showed posterior cerebral edema and in one case hemorrhagic complication. With symptomatic treatment and immunosuppressor withdrawal when they were previously used, symptoms fully resolved within 15 days in all cases, but one who had only partial regression related to cerebral hemorrhage. Including our cases, we reviewed a total of 46 patients with SLE and PRES. Their clinical and radiological presentation was not specific. The peculiar role of SLE itself in the occurrence of PRES was not clear, since hypertension (95%), renal involvement (91%), recent onset of immunosuppressive drugs (54%) and/or recent treatment with high intravenous dose of steroids (43%) were often present. The hypertension and other worsening factors should be treated. Finally, the evolution of this clinical and radiological spectacular syndrome is generally rapidly favorable.
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Affiliation(s)
- G Leroux
- Department of Internal Medicine, Centre Hospitalier Universitaire Pitié-Salpêtrière, 83 Boulevard de l'Hôpital, 75013 Paris, France
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