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Shimamoto Y, Sasaki H, Kasuno K, Watanabe Y, Sakashita S, Nishikawa S, Nishimori K, Morita S, Nishikawa Y, Kobayashi M, Fukushima S, Enomoto S, Takahashi N, Hamano T, Sakamaki I, Iwasaki H, Iwano M. Posterior reversible encephalopathy syndrome (PRES) associated with SARS-CoV-2 infection in a patient under maintenance haemodialysis: a case report. BMC Nephrol 2023; 24:286. [PMID: 37773103 PMCID: PMC10542676 DOI: 10.1186/s12882-023-03319-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/04/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Endothelial dysfunction is common in patients undergoing chronic haemodialysis, and is a major cause of posterior reversible encephalopathy syndrome (PRES). Recently, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been shown to cause endothelial dysfunction by infecting vascular endothelial cells. Several cases of neurological complications in patients without kidney dysfunction, and only a few cases in patients with chronic kidney disease, have been reported in the literature. However, no previous report has yet described PRES associated with SARS-CoV-2 infection among patients undergoing maintenance dialysis. CASE PRESENTATION A 54-year-old woman undergoing maintenance haemodialysis was admitted to our hospital for status epilepticus. She had developed end-stage kidney disease (ESKD) secondary to diabetic nephropathy. Seven days prior to admission, she had developed fever and was diagnosed with COVID-19. Subsequently her blood pressure increased from 160/90 mmHg to 190/100 mmHg. On admission, she presented with severe hypertension (> 220/150 mmHg), unconsciousness, and epilepticus. CT tomography revealed no signs of brain haemorrhage. Cranio-spinal fluid (CSF) examination revealed no signs of encephalitis, and CSF polymerase chain reaction (PCR) for SARS-CoV-2 was negative. MRI findings revealed focal T2/FLAIR hyperintensity in the bilateral parietooccipital regions, leading to the diagnosis of PRES. Deep sedation and strict blood pressure control resulted in a rapid improvement of her symptoms, and she was discharged without sequelae. CONCLUSIONS We report the first case of PRES associated with SARS-CoV-2 infection in a patient undergoing maintenance haemodialysis. Patients undergoing maintenance haemodialysis are at high risk of PRES because of several risk factors. SARS-CoV-2 infection causes direct invasion of endothelial cells by binding to angiotensin-converting enzyme 2 (ACE2), initiating cytokine release, and hypercoagulation, leading to vascular endothelial cell injury and increased vascular leakage. In the present case, SARS-CoV-2 infection possibly be associated with the development of PRES.
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Affiliation(s)
- Yuki Shimamoto
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Hirohito Sasaki
- Division of Neurology, Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kenji Kasuno
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan.
| | - Yuki Watanabe
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Sayumi Sakashita
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Sho Nishikawa
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Kazuhisa Nishimori
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Sayu Morita
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Yudai Nishikawa
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Mamiko Kobayashi
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Sachiko Fukushima
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Soichi Enomoto
- Division of Neurology, Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Naoki Takahashi
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
| | - Tadanori Hamano
- Division of Neurology, Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ippei Sakamaki
- Department of Infectious Diseases, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hiromichi Iwasaki
- Division of Infection Control and Prevention, University of Fukui Hospital, Fukui, Japan
| | - Masayuki Iwano
- Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan
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Ndu IK, Ayuk AC, Onukwuli VO. Challenges of Diagnosing Pediatric Posterior Reversible Encephalopathy Syndrome in Resource Poor Settings: A Narrative Review. Glob Pediatr Health 2020; 7:2333794X20947924. [PMID: 32851119 PMCID: PMC7425312 DOI: 10.1177/2333794x20947924] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/10/2020] [Accepted: 07/16/2020] [Indexed: 11/17/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare clinical syndrome that has been observed in different age groups, including pediatric patients. Identified triggers of PRES in both children and adults have included immunosuppressive and cytotoxic agents, organ transplantation, severe sepsis, blood transfusion, or evidence of human immunodeficiency virus-1 (HIV-1). Its clinical and radiological courses have been reported as mostly benign and reversible over days to weeks. Computed tomography (CT) scans are helpful in diagnosis, but magnetic resonance imaging (MRI) remains the gold standard. Unfortunately, because of the prohibitive costs of such medical equipment, diagnosis remains a challenge in developing countries. There is a dearth of information about pediatric PRES in resource-poor settings. This narrative aims to draw attention to the possible existence of PRES in children and to identify factors responsible for the difficulty in making the diagnosis. This review will hopefully increase awareness of PRES among pediatricians in order to make early diagnosis and institute appropriate management of this condition.
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Uremic encephalopathy in patients undergoing assisted peritoneal dialysis: a case series and literature review. CEN Case Rep 2019; 8:271-279. [PMID: 31177383 DOI: 10.1007/s13730-019-00406-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022] Open
Abstract
We sometimes hesitate to switch renal replacement therapy from peritoneal dialysis (PD) particularly in elderly patients due to their physical tolerance levels and lifestyles. Here, we describe the cases of three patients treated with PD alone despite an anuric status who subsequently developed uremic encephalopathy, which was successfully treated with hemodialysis (HD). The first patient was a 75-year-old woman who developed uremic encephalopathy with an anuric status and inadequate PD after 7 months of treatment. HD immediately improved her condition; encephalopathy did not recur with combined therapy of PD and HD. The second patient was a 69-year-old woman who developed anuria and was treated with combined therapy. Her arteriovenous fistula was obstructed; therefore, she was treated with PD alone. Total weekly Kt/V was sufficiently high at 1.95; however, she developed uremic encephalopathy the following month, which was successfully treated with HD. The third patient was an 84-year-old woman who developed anuria, but was treated with PD alone with adequate total weekly Kt/V of 2.2. PD could not be performed for 2 days because of myocardial infarction intervention; subsequently, she developed uremic encephalopathy, which was successfully treated with HD. These cases are the first of their kinds, wherein patients undergoing PD, developed uremic encephalopathy without any obvious triggers, including drugs, and illustrate the necessity of initiating combined therapy for such patients considering the risk of developing severe uremia leading to uremic encephalopathy, in spite of it being less preferable for elderly patients due to their physical conditions and lifestyles.
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Daptomycin-Induced Posterior Reversible Encephalopathy Syndrome (PRES). Case Rep Neurol Med 2019; 2019:8756932. [PMID: 30918728 PMCID: PMC6408990 DOI: 10.1155/2019/8756932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/04/2019] [Accepted: 02/05/2019] [Indexed: 11/17/2022] Open
Abstract
AIMS To present a 60-year-old female patient who manifested clinical and radiological features of posterior reversible encephalopathy syndrome (PRES) following the administration of Daptomycin for glycopeptide-resistant Enterococcal urinary tract infection. MATERIAL Case report. METHOD Posterior reversible encephalopathy syndrome was diagnosed in our patient following the administration of Daptomycin based on clinical suspicion as well as brain CT and MRI imaging. RESULTS The temporal association between the initiation of Daptomycin and the onset of PRES is highly suggestive of causality, and this is further supported by clinical and radiological resolution after Daptomycin was withdrawn. CONCLUSION This is the first report of Daptomycin-induced posterior reversible encephalopathy syndrome.
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Largeau B, Le Tilly O, Sautenet B, Salmon Gandonnière C, Barin-Le Guellec C, Ehrmann S. Arginine Vasopressin and Posterior Reversible Encephalopathy Syndrome Pathophysiology: the Missing Link? Mol Neurobiol 2019; 56:6792-6806. [PMID: 30924075 DOI: 10.1007/s12035-019-1553-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 03/13/2019] [Indexed: 12/12/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological entity characterized by a typical brain edema. Its pathogenesis is still debated through hypoperfusion and hyperperfusion theories, which have many limitations. As PRES occurs almost exclusively in clinical situations with arginine vasopressin (AVP) hypersecretion, such as eclampsia and sepsis, we hypothesize that AVP plays a central pathophysiologic role. In this review, we discuss the genesis of PRES and its symptoms through this novel approach. We theorize that AVP axis stimulation precipitates PRES development through an increase in AVP secretion or AVP receptor density. Activation of vasopressin V1a receptors leads to cerebral vasoconstriction, causing endothelial dysfunction and cerebral ischemia. This promotes cytotoxic edema through hydromineral transglial flux dysfunction and may increase endothelial permeability, leading to subsequent vasogenic brain edema. If our hypothesis is confirmed, it opens new perspectives for better patient monitoring and therapies targeting the AVP axis in PRES.
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Affiliation(s)
- Bérenger Largeau
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France.
| | - Olivier Le Tilly
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Bénédicte Sautenet
- Université de Tours, Université de Nantes, INSERM, Methods in patients-centered outcomes and health research (SPHERE) - UMR 1246, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, Tours, France
| | | | - Chantal Barin-Le Guellec
- Université de Tours, Université de Limoges, INSERM, Individual profiling and prevention of risks with immunosuppressive therapies and transplantation (IPPRITT) - UMR 1248, CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Stephan Ehrmann
- Université de Tours, INSERM, Centre d'étude des pathologies respiratoires (CEPR) - UMR 1100, CHRU de Tours, Service de Médecine Intensive Réanimation, CIC 1415, réseau CRICS-TRIGGERSEP, Tours, France
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Kaneko S, Hirai K, Minato S, Yanai K, Mutsuyoshi Y, Ishii H, Kitano T, Shindo M, Aomatsu A, Miyazawa H, Ito K, Ueda Y, Hoshino T, Ookawara S, Morishita Y. A case of posterior reversible encephalopathy syndrome in a patient undergoing automated peritoneal dialysis. CEN Case Rep 2019; 8:178-182. [PMID: 30830671 DOI: 10.1007/s13730-019-00389-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 02/18/2019] [Indexed: 10/27/2022] Open
Abstract
A 44-year-old man undergoing automated peritoneal dialysis (PD) developed headache and dizziness with truncal ataxia and ataxic gait. Severe hypertension (systolic blood pressure/diastolic pressure: 193/83 mm Hg) and lower extremity edema were present, and his PD efficiency (weekly KT/V: 1.49) was inadequate. Magnetic resonance imaging revealed diffuse hyperintensities in the brain stem and bilateral cerebellar hemispheres on fluid-attenuated inversion recovery and apparent diffusion coefficient mapping imaging. Based on these findings, the patient was diagnosed with posterior reversible encephalopathy syndrome due to hypertension and uremia. He was treated with antihypertensive agents, and we changed the PD prescription to improve PD efficiency. Thereafter, his symptoms gradually improved, and abnormal findings on brain magnetic resonance imaging disappeared in accordance with lowering blood pressure.
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Affiliation(s)
- Shohei Kaneko
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan.
| | - Saori Minato
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Katsunori Yanai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Yuko Mutsuyoshi
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Hiroki Ishii
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Taisuke Kitano
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Mitsutoshi Shindo
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Akinori Aomatsu
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Haruhisa Miyazawa
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Yuichirou Ueda
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Taro Hoshino
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
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Smets GJ, Loyson T, Van Paesschen W, Demaerel P, Nackaerts K. Posterior reversible encephalopathy syndrome possibly induced by pemetrexed maintenance therapy for lung cancer: a case report and literature review. Acta Clin Belg 2018; 73:382-388. [PMID: 29173113 DOI: 10.1080/17843286.2017.1403103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction Advances in systemic chemotherapy, molecular targeted therapy and immunotherapy have extended and improved the quality of life of patients with cancer. However, the central nervous system is very susceptible to complications of systemic cancer and its treatment. Posterior reversible encephalopathy syndrome (PRES) is a rare clinical and neuroradiologic entity which has garnered increasing recognition in the past two decades. Cancer patients are generally treated with cytotoxic agents, immunotherapy, molecular targeted therapies or glucosteroids which are more frequently associated with PRES. Case presentation A 59-year old female, known with a relapse of her lung adenocarcinoma, had been treated with 4 cycles of cisplatin (75 mg/m²) and pemetrexed (500 mg/m²). Six weeks after this combination chemotherapy and within 28 h after the administration of pemetrexed maintenance therapy, she developed a generalised epileptic insult. Magnetic resonance imaging (MRI) of the brain showed bilateral areas of increased signal intensity in the subcortical parietal and frontal white matter. She was treated with a broad spectrum antiseizure drug, levetiracetam 750 mg twice daily and strict control of blood pressure. Discussion Diagnosis of PRES should be considered in all patients with neurologic symptoms who are at risk to develop PRES. It is crucial to establish the diagnosis as soon as possible since there is no specific treatment of PRES other than correction of the underlying risk factors and preventing seizure recurrence. Administration of pemetrexed is a possible risk factor for the development of PRES.
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Affiliation(s)
- Gert-Jan Smets
- Clinical Department of Pneumology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Tine Loyson
- Clinical Department of Oncology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Wim Van Paesschen
- Clinical Department of Neurology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Philippe Demaerel
- Clinical Department of Radiology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Kristiaan Nackaerts
- Clinical Department of Pneumology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
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Moreiras-Plaza M, Fernández-Fleming F, Azkárate-Ramírez N, Nájera-de la Garza W, Martín-Baez I, Hernansanz-Pérez M. Peritoneal dialysis: A factor of risk or protection for posterior reversible encephalopathy syndrome? review of the literature. Nefrologia 2018; 38:136-140. [PMID: 29409679 DOI: 10.1016/j.nefro.2017.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/12/2017] [Accepted: 03/19/2017] [Indexed: 11/26/2022] Open
Abstract
Posterior reversible encephalopathy syndrome is a clinical and radiological entity with acute or subacute neurological presentation associated with brain lesions that primarily affect the white matter of the posterior regions. It is often associated with the rapid onset of severe hypertension and/or with kidney failure (acute and chronic), but it has also been reported as a neurological complication in several medical conditions. In recent years, there has been an increase in the number of cases and related publications due to the advance of diagnostic imaging techniques. The characteristic radiological finding includes hyperintense lesions in T2- and FLAIR-weighted magnetic resonance imaging, which are often bilateral and located in the posterior cerebral regions and correspond to areas of vasogenic oedema. Little is known about the pathophysiology of posterior reversible encephalopathy syndrome. The most accepted theory, especially in cases with associated hypertension, is the loss of cerebral self-regulation which leads to the onset of vasogenic oedema. The main feature of this syndrome is the reversibility of both symptoms and cerebral lesions with an early and appropriate diagnosis. Despite the frequent association with kidney failure and severe hypertension, there are few cases reported in patients on peritoneal dialysis. This article presents a review of PRES in peritoneal dialysis patients in the published literature.
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Affiliation(s)
| | | | | | | | - Isabel Martín-Baez
- Servicio de Nefrología, Complexo Hospitalario Universitario de Vigo, Vigo, España
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Jia LJ, Qu ZZ, Zhang XQ, Tian YJ, Wang Y. Uremic encephalopathy with isolated brainstem involvement revealed by magnetic resonance image: a case report. BMC Neurol 2017; 17:154. [PMID: 28789642 PMCID: PMC5549307 DOI: 10.1186/s12883-017-0936-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/01/2017] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Uremic Encephalopathy (UE) is a neurological complication associated with acute or chronic renal failure. Imaging findings of UE may present involvement of the basal ganglia, cortical or subcortical regions, and white matter. We report a rare case of UE caused by neurogenic bladder with isolated brainstem involvement revealed by magnetic resonance imaging (MRI). Immediate therapy resulted in full recovery of neurological signs and changes on MRI. CASE PRESENTATION A 14-year-old Han Chinese woman with a history of chronic renal failure caused by neurogenic bladder. On admission, she was unconscious and her pupils presented different sizes, while her vital signs were normal. MRI showed high signal in the dorsal pontine base and in the mid brain on fluid-attenuated inversion-recovery (FLAIR) imaging and on T2-weighted imaging while the signal was normal on diffusion-weighted images (DWI). Blood analysis revealed renal failure and acidosis. After urinary retention treatment and acidosis correction, the patient soon recovered. Follow-up MRI 2 months after the discharge revealed complete resolution of UE in the brainstem. CONCLUSION We reported a rare case of a patient with UE that had unusual imaging manifestations for whom timely diagnosis and treatment assured recovery.
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Affiliation(s)
- Li-Jing Jia
- Department of Neurology, The Second Hospital of Hebei Medical University, Hebei, Shijiazhuang, 050000, People's Republic of China. .,Institution of Cardiocerebrovascular Disease, Hebei, West Heping Road 215, Shijiazhuang, 050000, People's Republic of China. .,Neurological Laboratory of Hebei Province, Hebei, Shijiazhuang, 050000, People's Republic of China.
| | - Zhen-Zhen Qu
- Department of Neurology, The Second Hospital of Hebei Medical University, Hebei, Shijiazhuang, 050000, People's Republic of China.,Institution of Cardiocerebrovascular Disease, Hebei, West Heping Road 215, Shijiazhuang, 050000, People's Republic of China.,Neurological Laboratory of Hebei Province, Hebei, Shijiazhuang, 050000, People's Republic of China
| | - Xue-Qian Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Hebei, Shijiazhuang, 050000, People's Republic of China
| | - Yu-Juan Tian
- Department of Neurology, The Second Hospital of Hebei Medical University, Hebei, Shijiazhuang, 050000, People's Republic of China
| | - Ying Wang
- Department of Neurology, The Second Hospital of Hebei Medical University, Hebei, Shijiazhuang, 050000, People's Republic of China
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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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Lax NZ, Gorman GS, Turnbull DM. Review: Central nervous system involvement in mitochondrial disease. Neuropathol Appl Neurobiol 2016; 43:102-118. [PMID: 27287935 PMCID: PMC5363248 DOI: 10.1111/nan.12333] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 06/03/2016] [Accepted: 06/11/2016] [Indexed: 12/13/2022]
Abstract
Mitochondrial respiratory chain defects are an important cause of inherited disorders affecting approximately 1 in 5000 people in the UK population. Collectively these disorders are termed ‘mitochondrial diseases’ and they result from either mitochondrial DNA mutations or defects in nuclear DNA. Although they are frequently multisystem disorders, neurological deficits are particularly common, wide‐ranging and disabling for patients. This review details the manifold neurological impairments associated with mitochondrial disease, and describes the efforts to understand how they arise and progressively worsen in patients with mitochondrial disease. We describe advances in our understanding of disease pathogenesis through detailed neuropathological studies and how this has spurred the development of cellular and animal models of disease. We underscore the importance of continued clinical, molecular genetic, neuropathological and animal model studies to fully characterize mitochondrial diseases and understand mechanisms of neurodegeneration. These studies are instrumental for the next phase of mitochondrial research that has a particular emphasis on finding novel ways to treat mitochondrial disease to improve patient care and quality of life.
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Affiliation(s)
- N Z Lax
- The Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - G S Gorman
- The Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - D M Turnbull
- The Wellcome Trust Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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Tang JH, Tian JM, Sheng M, Hu SY, Li Y, Zhang LY, Gu Q, Wang Q. Study of Posterior Reversible Encephalopathy Syndrome in Children With Acute Lymphoblastic Leukemia After Induction Chemotherapy. J Child Neurol 2016; 31:279-84. [PMID: 26060305 DOI: 10.1177/0883073815589758] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/21/2015] [Indexed: 12/16/2022]
Abstract
Increasing occurrence of posterior reversible encephalopathy syndrome has been reported in children with acute lymphoblastic leukemia. However, the etiology of posterior reversible encephalopathy syndrome is not clear. To study the possible pathogenetic mechanisms and treatment of this complication, we reported 11 cases of pediatric acute lymphoblastic leukemia who developed posterior reversible encephalopathy syndrome after induction chemotherapy. After appropriate treatment, the clinical symptoms of posterior reversible encephalopathy syndrome in most cases disappeared even though induction chemotherapy continued. During the 1-year follow-up, no recurrence of posterior reversible encephalopathy syndrome was observed. Although the clinical and imaging features of posterior reversible encephalopathy syndrome may be diverse, posterior reversible encephalopathy syndrome should be recognized as a possible important complication of acute lymphoblastic leukemia when neurologic symptoms appear. In line with previous reports, our study also indicated that posterior reversible encephalopathy syndrome was reversible when diagnosed and treated at an early stage. Thus, the occurrence of posterior reversible encephalopathy syndrome should be considered and investigated to optimize the early induction scheme of acute lymphoblastic leukemia treatment.
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Affiliation(s)
- Ji-Hong Tang
- Department of Neurology, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Jian-Mei Tian
- Department of Internal Medicine, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Mao Sheng
- Radiology Department, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Shao-Yan Hu
- Department of Hematology and Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Yan Li
- Department of Neurology, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Li-Ya Zhang
- Department of Hematology and Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Qing Gu
- Department of Neurology, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Qi Wang
- Radiology Department, Children's Hospital Affiliated to Soochow University, Suzhou, China
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13
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Sakai R, Sakurai S, Okada T, Takahashi T, Hayakawa S, Koji H, Iwasaki M, Iwamoto K. [Case Report: Atypical posterior reversible encephalopathy syndrome (PRES) and thrombotic microangiopathy (TMA) in a hemodialysis patient with ANCA-associated vasculitis: a case report]. ACTA ACUST UNITED AC 2016; 105:275-9. [PMID: 27228724 DOI: 10.2169/naika.105.275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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Iwafuchi Y, Okamoto K, Oyama Y, Narita I. Posterior Reversible Encephalopathy Syndrome in a Patient with Severe Uremia without Hypertension. Intern Med 2016; 55:63-8. [PMID: 26726088 DOI: 10.2169/internalmedicine.55.5563] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 28-year-old man was admitted to our hospital with nausea, headache and weakness of the left hand. He had severe uremia without hypertension due to recurrent/chronic pyelonephritis. Brain magnetic resonance imaging showed reversible vasogenic edema in the brainstem and bilateral frontal centrum semiovale. All of his neurological symptoms immediately improved after the introduction of hemodialysis. When a patient with uremia presents with neurological symptoms, posterior reversible encephalopathy syndrome should be considered in the differential diagnosis even if high blood pressure is not observed. Brain magnetic resonance imaging may be helpful in such a case, and an appropriate therapy could be subsequently initiated.
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Affiliation(s)
- Yoichi Iwafuchi
- Department of Internal Medicine, Koseiren Sanjo General Hospital, Japan
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15
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Posterior Reversible Encephalopathy Syndrome After Transplantation: a Review. Mol Neurobiol 2015; 53:6897-6909. [PMID: 26666662 DOI: 10.1007/s12035-015-9560-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 11/29/2015] [Indexed: 12/29/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disease. Recently, an increase in the number of transplantations has led to more cases being associated with PRES than what was previously reported. Calcineurin inhibitors (CNIs) are major risk factors for PRES in posttransplantation patients. The mechanisms of the development of PRES remain to be unclear. The typical clinical symptoms of PRES include seizures, acute encephalopathy syndrome, and visual symptoms. The hyperintense signal on fluid-attenuated inversion recovery image is the characteristic of the imaging appearance in these patients. In addition, other abnormal signals distributed in multiple locations are also reported in some atypical cases. Unfortunately, PRES is often not recognized or diagnosed too late due to complicated differential diagnoses, such as ischemic stroke, progressive multifocal leukoencephalopathy, and neurodegenerative diseases. Thus, this review emphasizes the importance of considering the possibility of PRES when neurological disturbances appear after solid organ transplantation or hematopoietic cell transplantation. Moreover, this review demonstrates the molecular mechanisms of PRES associated with CNIs after transplantation, which aims to help clinicians further understand PRES in the transplantation era.
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16
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Ge YT, Liao JL, Liang W, Xiong ZY. Anti-Glomerular Basement Membrane Disease Combined with IgA Nephropathy Complicated with Reversible Posterior Leukoencephalopathy Syndrome: An Unusual Case. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:849-53. [PMID: 26621456 PMCID: PMC4671450 DOI: 10.12659/ajcr.894619] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Male, 24 Final Diagnosis: Crescentic glomerulonephritis (type I) with IgA nephropathy Symptoms: Headache • gross hematuria • nocturia • seizures Medication: Cyclophosphamide Clinical Procedure: Dignosis to treatment Specialty: Nephrology
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Affiliation(s)
- Ya-ting Ge
- Department of Nephrology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Jin-lan Liao
- Department of Nephrology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Wei Liang
- Department of Nephrology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Zu-ying Xiong
- Department of Nephrology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
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17
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Granata G, Greco A, Iannella G, Granata M, Manno A, Savastano E, Magliulo G. Posterior reversible encephalopathy syndrome--Insight into pathogenesis, clinical variants and treatment approaches. Autoimmun Rev 2015; 14:830-6. [PMID: 25999210 DOI: 10.1016/j.autrev.2015.05.006] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 05/12/2015] [Indexed: 01/20/2023]
Abstract
Posterior reversible encephalopathy syndrome is a rare clinicoradiological entity characterized by typical MRI findings located in the occipital and parietal lobes, caused by subcortical vasogenic edema. It was first described as a distinctive syndrome by Hinchey in 1996. Etiopathogenesis is not clear, although it is known that it is an endotheliopathy of the posterior cerebral vasculature leading to failed cerebral autoregulation, posterior edema and encephalopathy. A possible pathological activation of the immune system has been recently hypothesized in its pathogenesis. At clinical onset, the most common manifestations are seizures, headache and visual changes. Besides, tinnitus and acute vertigo have been frequently reported. Symptoms can be reversible but cerebral hemorrhage or ischemia may occur. Diagnosis is based on magnetic resonance imaging, in the presence of acute development of clinical neurologic symptoms and signs and arterial hypertension and/or toxic associated conditions with possible endotheliotoxic effects. Mainstay on the treatment is removal of the underlying cause. Further investigation and developments in endothelial cell function and in neuroimaging of cerebral blood flow are needed and will help to increase our understanding of pathophysiology, possibly suggesting novel therapies.
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Affiliation(s)
- Guido Granata
- Department of Clinical Immunology, Sapienza University of Rome, Viale dell'Università, 37, 00161 Rome, Italy.
| | - Antonio Greco
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Giannicola Iannella
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Massimo Granata
- Department of Clinical Immunology, Sapienza University of Rome, Viale dell'Università, 37, 00161 Rome, Italy.
| | - Alessandra Manno
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Ersilia Savastano
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
| | - Giuseppe Magliulo
- Organi di Senso Department University, Sapienza University of Rome, Viale del Policlinico, 151, 00161 Rome, Italy.
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18
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Canney M, Kelly D, Clarkson M. Posterior reversible encephalopathy syndrome in end-stage kidney disease: not strictly posterior or reversible. Am J Nephrol 2015; 41:177-82. [PMID: 25871433 DOI: 10.1159/000381316] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an uncommon clinico-radiological condition that can result in severe brain injury. The pathogenesis of cerebral vasogenic edema, the hallmark of PRES, is not fully understood. Despite its name, there is substantial heterogeneity both in terms of imaging findings and outcome. Relatively little is known about PRES in kidney disease despite the clustering of risk factors including hypertension, autoimmune disease and immunosuppression. In a retrospective observational study of incident end-stage kidney disease patients in Southwest Ireland over a ten year period, we discovered five cases of PRES representing an incidence of 0.84% in this patient population. These five cases highlight the variability in clinical presentation and the potentially life-threatening nature of this condition. We provide an in-depth review of the existing literature regarding PRES in terms of its pathogenesis and heterogeneity, as well as the experience of PRES in ESKD patients. PRES appears to be rare in the ESKD population but could be under-recognized. Marked hypertension is a cardinal risk factor in this population, associated with extracellular fluid volume expansion. Neuroimaging findings can be diverse involving both anterior and posterior circulation territories. Three of the five patients described had commenced haemodialysis within four weeks of their presentation. These patients may be particularly vulnerable to microvascular brain injury, which can be devastating. This emphasises the need for clinicians to pay meticulous attention to extracellular fluid volume control during this potentially hazardous period.
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Affiliation(s)
- Mark Canney
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
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19
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Hayashi R, Kitazawa K, Sanada D, Kato N, Ohkoshi T, Katsumata Y, Yamaguchi S. Diffuse Leukoencephalopathy Associated with Dialysis Disequilibrium Syndrome. Intern Med 2015; 54:2753-8. [PMID: 26521906 DOI: 10.2169/internalmedicine.54.4938] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 52-year-old woman, previously treated for gastric cancer, began hemodialysis (HD) to treat the onset of severe acidemia. After her initial HD sessions, she suffered from a prolonged coma for approximately ten days. Magnetic resonance imaging revealed diffuse leukoencephalopathy, with increased apparent diffusion coefficient. Magnetic resonance spectroscopy showed a reduction of the N-acetylaspartate/creatine ratio. Her neuroimaging findings gradually resolved. Her transient cerebral white matter lesions were thought to be interstitial edema derived from dialysis disequilibrium syndrome (DDS), which might have been amplified by subclinical brain injury due to past chemotherapy. Her history of cancer chemotherapy may be a risk factor for an exacerbation of DDS.
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Affiliation(s)
- Ryuichiro Hayashi
- Department of Neurology, Yokohama Municipal Citizen's Hospital, Japan
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