Posterior Reversible Encephalopathy Syndrome Associated with FOLFOX Chemotherapy

Abstract Background Posterior Reversible Encephalopathy Syndrome (PRES) is an acute neurological entity characterized by headache, altered mental status, visual loss and seizures. It can be triggered by multiple aetiologies including hypertension, eclampsia, cytotoxic and immunosuppressant drugs and, rarely, hypercalcaemia. Case Report A 64 years old woman presented with five weeks history of fatigue, poor appetite, dry mouth, constipation and abdominal discomfort and one-week history of nausea and vomiting. She was hypertensive at 177/88 mmHg with dry mucous membranes. Physical examination and neurological examination were unremarkable. Laboratory investigation showed corrected calcium of 4.83 mmol/L (2.25-2.54) with Ionized calcium of 2.62 mmol/L (1.15-1.27), parathyroid hormone (PTH) of 1330 ng/l (15-68), phosphate of 1.16 mmol/L(0.8-1.5), magnesium of 0.51 mmol/L (0.7-1.0) urea of 10.7 mmol/L (2.8-8.4), creatinine of 119 umol/L (49-90), potassium 3.4 mmol/L(3.5-5.1). She was aggressively rehydrated, commenced on Intravenous (IV) frusemide and was given IV zoledronic acid. Cinacalcet was commenced and titrated gradually up according to corrected calcium level (target corrected calcium level between 2.5-3.0 mmol/L).Electrolytes deficiencies corrected with replacement therapy.Ultrasound neck and parathyroid MIBG scan showed large 5.1cm heterogeneous lesion posterior to the right lobe of the thyroid extending inferiorly into the superior mediastinum consistent with parathyroid mass. Histology confirmed benign parathyroid adenoma. 38 hours after admission, the patient became intermittently confused and complained of visual symptoms followed by complete visual loss in the left eye. This was followed shortly by status epilepticus which required treatment with intravenous antiepileptic therapy and mechanical ventilation.Corrected calcium at that time was 3.82 mmol/L.Patient was noted to have left upper limb weakness.Computed tomography of the brain was normal and magnetic resonance imaging (MRI) of the brain showed bilateral symmetrical subcortical T2 hyper- intensities in the occipital- parietal lobes consistent with PRES. By day five, corrected calcium was 2.52 mmol/L. On day six patient had successful parathyroidectomy. Post operatively PTH was 7.73 ng/L and corrected calcium 2.27 mmol/L. Repeated Brain MRI showed resolution of symmetrical subcortical T2 hyperintensities within both occipital lobes. She made a complete neurological recovery. DEXA scan showed osteoporosis (T score in left forearm of -3.8). She was commenced on bisphosphonate therapy. In conclusion, we demonstrated hypercalcemia-induced PRES. This can be a life-threatening condition and can be reversed by proper treatment of hypercalcemia.

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Posterior Reversible Encephalopathy Syndrome: A Case of Hypercalcemia

Acta Médica Portuguesa ◽

10.20344/amp.9714 ◽

2018 ◽

Vol 31 (6) ◽

pp. 338

Author(s):

Ana Ponciano ◽

Vera Vieira ◽

José Leite ◽

Célio Fernandes

Keyword(s):

Renal Failure ◽

Immunosuppressive Therapy ◽

Mental Status ◽

Posterior Reversible Encephalopathy Syndrome ◽

Altered Mental Status ◽

Normotensive Patient ◽

Posterior Reversible Encephalopathy ◽

Severe Hypercalcemia ◽

Reversible Encephalopathy

Posterior reversible encephalopathy syndrome is an encephalopathy that can be clinically characterized by headache, altered mental status and/or seizures. Neuroimaging demonstrates usually reversible bilateral subcortical vasogenic occipital-parietal edema. Exact pathophysiology remains unclear but is commonly associated with hypertension, renal failure, sepsis and use of immunosuppressive therapy. Its development in the setting of severe hypercalcemia is extremely rare. The authors report a case of posterior reversible encephalopathy syndrome in a normotensive patient with severe hypercalcemia as the only identifiable cause.

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Posterior Reversible Encephalopathy Syndrome (PRES) in Palliative Medicine: Case Report and Discussion

American Journal of Hospice and Palliative Medicine® ◽

10.1177/10499091211030465 ◽

2021 ◽

pp. 104990912110304

Author(s):

Jade Willey ◽

Steven J. Baumrucker

Keyword(s):

Case Report ◽

Mental Status ◽

Posterior Reversible Encephalopathy Syndrome ◽

Palliative Medicine ◽

Altered Mental Status ◽

Posterior Reversible Encephalopathy ◽

Reversible Encephalopathy ◽

Visual Disturbances

Posterior reversible encephalopathy syndrome (PRES) is associated with seizures, visual disturbances, headache, and altered mental status. Given its presentation, the diagnosis can be mistaken for other severe conditions. Palliative medicine consultants should be aware of PRES and be prepared to counsel families on the treatment and prognosis of this syndrome.

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Posterior Reversible Encephalopathy Syndrome Secondary to Hypertensive Encephalopathy Brought on by a MAO Inhibitor: A Case Report

Journal of Primary Care & Community Health ◽

10.1177/2150132719869539 ◽

2019 ◽

Vol 10 ◽

pp. 215013271986953 ◽

Cited By ~ 1

Author(s):

Robert Strother ◽

Hailon Wong ◽

Nathaniel E. Miller

Keyword(s):

White Matter ◽

Mental Status ◽

Posterior Reversible Encephalopathy Syndrome ◽

Altered Mental Status ◽

Hypertensive Encephalopathy ◽

Inpatient Service ◽

Mao Inhibitor ◽

Radiographic Findings ◽

Posterior Reversible Encephalopathy ◽

Reversible Encephalopathy

An elderly woman was admitted to the Family Medicine inpatient service for altered mental status after being brought to the emergency room by a concerned neighbor, who had come across the patient speaking incoherently. Initial evaluation was notable for elevated blood pressures, but extensive lab testing and head computed tomographic imaging were within normal limits. However, subsequent magnetic resonance imaging showed white matter changes consistent with posterior reversible encephalopathy syndrome (PRES), a neurologic syndrome characterized by headache, altered mental status, loss of vision, and seizures as well as radiographic findings of posterior cerebral white matter edema. Multiple etiologies of PRES have been described and include hypertensive encephalopathy, immunosuppressant medications, and eclampsia. This case describes an episode of PRES secondary to hypertensive encephalopathy brought about by an inappropriate dose of a monoamine oxidase (MAO) inhibitor. The patient had significant improvement in symptoms with removal of the offending agent and control of her blood pressure. While PRES generally has a good prognosis, prompt recognition, and management are important in preventing significant disease morbidity and mortality.

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Posterior Reversible Encephalopathy Syndrome in Pediatric Cancer: Clinical and Radiologic Findings

Journal of Global Oncology ◽

10.1200/jgo.17.00089 ◽

2018 ◽

pp. 1-8 ◽

Cited By ~ 5

Author(s):

Saadiya Javed Khan ◽

Arjumand Ali Arshad ◽

Mohammad Bilal Fayyaz ◽

Islah ud din Mirza

Keyword(s):

B Cell ◽

Hodgkin Lymphoma ◽

Mental Status ◽

Posterior Reversible Encephalopathy Syndrome ◽

Altered Mental Status ◽

Cell Leukemia ◽

Posterior Reversible Encephalopathy ◽

Radiologic Findings ◽

B Cell Leukemia ◽

Reversible Encephalopathy

Purpose Posterior reversible encephalopathy syndrome (PRES) is associated with a range of medical conditions and medications. In this retrospective analysis, we present 19 pediatric patients with PRES who had undergone chemotherapy. Methods We identified four female and 15 male patients diagnosed with PRES on the basis of clinical and radiologic features. Patient charts were reviewed from January 2013 to June 2016 after authorization from the institutional review board. Results The average age of patients with PRES was 7 years. Primary diagnoses were non-Hodgkin lymphoma (n = 9), acute pre–B-cell leukemia (n = 5), relapsed pre–B-cell leukemia (n = 2), Hodgkin lymphoma (n = 2), and Ewing sarcoma (n = 1). PRES occurred during induction chemotherapy in 12 patients. Sixteen patients had hypertension when they developed PRES. Most of these patients (n = 13) were receiving corticosteroids on diagnosis of PRES. Common clinical features were hypertension, seizures, and altered mental status. With the exclusion of three patients, all others required antiepileptic therapy. Ten of these patients underwent additional magnetic resonance imaging. Ten patients are still alive. Conclusion In patients who presented to our center with signs and symptoms of hypertension, seizures, visual loss, or altered mental status, PRES was mostly seen in those who were undergoing systemic and intrathecal chemotherapy. Approximately 40% of the patients had reversal of clinical and radiologic findings. Antiepileptic medications were discontinued after being seizure free for approximately 6 months.

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Posterior reversible encephalopathy syndrome in a patient with diabetic ketonuria

Journal of Kathmandu Medical College ◽

10.3126/jkmc.v8i4.32390 ◽

2020 ◽

Vol 8 (4) ◽

pp. 231-234

Author(s):

Ishwor Sharma ◽

Prakash Banjade ◽

Sasikumar Atthipalayam Chellamuthu ◽

Faisal Saeed ◽

Prajut Dallakoti

Keyword(s):

Diabetes Mellitus ◽

Type 2 Diabetes ◽

Type 2 Diabetes Mellitus ◽

Mental Status ◽

Posterior Reversible Encephalopathy Syndrome ◽

Stable Condition ◽

Altered Mental Status ◽

Posterior Reversible Encephalopathy ◽

Reversible Encephalopathy

Posterior reversible encephalopathy syndrome is a condition presenting with non-specific symptoms like nausea, vomiting and headache along with neurological manifestations like altered mental status, seizure, visual impairment and even coma. These symptoms are coupled with characteristic radiological findings of vasogenic edema in the bilateral parieto-occipital lobe which is usually reversible. We present here, a young 30 years old male, with dizziness, vomiting, generalized weakness, altered mental status with cortical blindness and focal and generalized tonic-clonic seizures in the background of first presentation of type 2 diabetes mellitus with ketonuria. Characteristic findings in Magnetic Resonance Imaging and reversal of the symptoms helped to reach the diagnosis of posterior reversible encephalopathy syndrome in our patient. The patient was discharged in stable condition after reversal of the symptoms and treatment of type 2 diabetes mellitus.

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Posterior reversible encephalopathy syndrome following Miller-Fisher syndrome

BMJ Case Reports ◽

10.1136/bcr-2021-242231 ◽

2021 ◽

Vol 14 (7) ◽

pp. e242231

Author(s):

Catarina Bernardes ◽

Cristiana Silva ◽

Gustavo Santo ◽

Inês Correia

Keyword(s):

Intravenous Immunoglobulin ◽

Posterior Reversible Encephalopathy Syndrome ◽

Brain Mri ◽

Clonic Seizure ◽

Miller Fisher Syndrome ◽

Fisher Syndrome ◽

Posterior Reversible Encephalopathy ◽

Fluid Analysis ◽

Immunoglobulin Treatment ◽

Reversible Encephalopathy

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.

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A broad spectrum of posterior reversible encephalopathy syndrome - a case series with clinical and paraclinical characterisation, and histopathological findings

BMC Neurology ◽

10.1186/s12883-021-02408-0 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Fatme Seval Ismail ◽

Johannes van de Nes ◽

Ilka Kleffner

Keyword(s):

Posterior Reversible Encephalopathy Syndrome ◽

Clinical Symptoms ◽

Brain Mri ◽

Case Series ◽

Epileptic Seizures ◽

Retrospective Case ◽

Posterior Reversible Encephalopathy ◽

Histopathological Findings ◽

Delay In Diagnosis ◽

Reversible Encephalopathy

Abstract Background Posterior reversible encephalopathy syndrome (PRES) is clinical-neuroradiologically defined and potentially reversible, so there are limited data about histopathological findings. We aimed to describe the clinical and paraclinical features of patients with PRES with regard to its reversibility. Methods This retrospective case series encompasses 15 PRES cases out of 1300 evaluated patients from a single German center between January 1, 2010, and June 15, 2020. PRES was established according to the diagnostic criteria as proposed by the Berlin PRES Study 2012. One of the cases studied was subject to brain autopsy. Results From the 15 patients studied (median age 53 years, range 17–73; 11 female), 67 % presented with epileptic seizures, 40 % suffered from encephalopathy with reduced consciousness and 53 % developed delirium, while 47 % had headache and visual disturbances. Subcortical brain MRI abnormalities related to PRES were observed in all patients. One patient developed spinal ischemia and another Guillain-Barré syndrome in addition to PRES. Hypertensive blood pressure was the main underlying/trigger condition in all patients. Clinical symptoms and MRI changes were not reversible in 42 %, even progressive in 3 out of these 5 patients. Median time from symptom onset to diagnosis in these non-reversible cases was 7 days (range 0–13), while the median delay in diagnosis in the reversible group was 1 day (range 0–3). Cerebellar/brain stem involvement and status epilepticus were more frequently in patients with non-reversible disease course. Mortality due to PRES occurred in 13 % of these patients. Neuropathological examination of the brain of a 57-year-old female patient revealed major leukencephalopathic changes, fibrinoid necrosis of endothelial cells and fresh petechial hemorrhages in accordance with PRES. Conclusions Our case series demonstrates that PRES was not reversible in 42 % of the studied patients. Delay in diagnosis seems to contribute to limited reversibility and poor outcome.

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Posterior Reversible Encephalopathy Syndrome Following Diabetic Ketoacidosis: A Case Report

10.21203/rs.3.rs-495918/v1 ◽

2021 ◽

Author(s):

Meng-Ko Tsai ◽

Chao-Hung Lai ◽

Tsung-Ju Chuang

Keyword(s):

Case Report ◽

Diabetic Ketoacidosis ◽

Blood Sugar ◽

Posterior Reversible Encephalopathy Syndrome ◽

Brain Mri ◽

Posterior Reversible Encephalopathy ◽

First Case ◽

Aged Woman ◽

Adequate Hydration ◽

Reversible Encephalopathy

Abstract Background Posterior reversible encephalopathy syndrome (PRES) following the development of diabetic ketoacidosis (DKA) is rare and usually occurs in children. This is the first case of DKA following PRES that we know of that occurred in an adult.Case report We encountered a middle-aged woman with a one-day history of nausea and vomiting who presented with DKA and seizure, along with hallucinations. On presentation, we performed physical examinations and blood biochemistry tests to ascertain the cause of these symptoms. We also performed magnetic resonance imaging (MRI) of her brain, which showed typical brain edema in the bilateral occipital and parietal regions, which indicated PRES. We treated the patient’s symptoms by administering adequate hydration and administering an infusion of insulin of 30 U after breakfast and 15 U after dinner to bring her blood sugar levels under control.The brain MRI we performed showed hyperintensity of the bilateral occipital and parietal cortexes on a fluid-attenuated inversion recovery T2 weighted image, after which the patient was diagnosed with PRES. The patient was discharged thirteen days after admission with stable blood sugar and blood pressure levels. Conclusions Physicians should keep this condition in mind as a possible complication of DKA and treat it quickly and efficiently in order to attain a good patient outcome.This is the first report of DKA-induced PRES in an adult, and physicians should keep this condition in mind as a possible complication of DKA, which is treatable and may have a good prognosis.

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Perioperative posterior reversible encephalopathy syndrome in 2 pediatric neurosurgery patients with brainstem ependymoma

Journal of Neurosurgery Pediatrics ◽

10.3171/2010.12.peds10299 ◽

2011 ◽

Vol 7 (3) ◽

pp. 235-237 ◽

Cited By ~ 6

Author(s):

Melanie G. Hayden Gephart ◽

Bonnie P. Taft ◽

Anne-Katrin Giese ◽

Raphael Guzman ◽

Michael S. B. Edwards

Keyword(s):

Mr Imaging ◽

Posterior Reversible Encephalopathy Syndrome ◽

Clinical Symptoms ◽

Pediatric Neurosurgery ◽

Altered Mental Status ◽

Hemodynamic Instability ◽

Imaging Features ◽

Posterior Reversible Encephalopathy ◽

Reversible Encephalopathy ◽

Pediatric Neurooncology

Posterior reversible encephalopathy syndrome (PRES) has been described in pediatric neurooncology patients, although it has not been documented perioperatively in pediatric neurosurgery patients not actively receiving chemotherapy. Recently at the authors' facility, 2 cases of PRES were diagnosed perioperatively in children with brainstem ependymoma. Both patients had presented with hypertension, altered mental status, and seizures and demonstrated MR imaging features consistent with PRES. The patients were treated with antiseizure and antihypertension medications, leading to improvement in both clinical symptoms and neuroimaging findings. These cases are the first to document PRES in perioperative pediatric neurosurgery patients not actively receiving chemotherapy. Both patients had ependymoma involving the brainstem, which may have led to intra- and perioperative hemodynamic instability (including hypertension) and predisposed them to this syndrome. An awareness of PRES in similar scenarios will aid in the prevention, diagnosis, and treatment of pediatric neurosurgery patients with this syndrome.

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