Calcineurin inhibitors-related posterior reversible encephalopathy syndrome in liver transplant recipients: Three case reports and review of literature

BACKGROUND Posterior reversible encephalopathy syndrome(PRES),characterized by acute neurological deterioration and extensive white matter lesions on T2-fluid attenuated inversion recovery magnetic resonance imaging(MRI),is increasingly associated with calcineurin inhibitors(CNI)-related neurotoxicity.Prompt diagnosis is crucial,as early intervention,including the modification or discontinuation of CNI therapy,strict blood pressure management,corticosteroid treatment,and supportive care can significantly improve patient outcomes and prognosis.The growing clinical recognition of CNI-related PRES underscores the importance of identifying and managing this condition in patients presenting with acute neurological symptoms.CASE SUMMARY This report describes three cases of liver transplant recipients who developed PRES.The first case involves a 60-year-old woman who experienced seizures,aphasia,and hemiplegia on postoperative day(POD)9,with MRI revealing ischemic foci followed by extensive white matter lesions.After replacing tacrolimus,her symptoms improved,and no significant MRI abnormalities were observed after three years of follow-up.The second case concerns a 54-year-old woman with autoimmune hepatitis who developed headaches,seizures,and extensive white matter demyelination on MRI on POD24.Following the switch to rapamycin and the initiation of corticosteroids,her symptoms resolved,and she was discharged on POD95.The third case details a 60-year-old woman with hepatocellular carcinoma who developed PRES,evidenced by brain MRI abnormal-ities on POD11.Transitioning to rapamycin and corticosteroid therapy led to her full recovery,and she was discharged on POD22.These cases highlight the critical importance of early diagnosis,CNI modification,and stringent management in improving outcomes for liver transplant recipients with CNI related PRES.CONCLUSION Clinical manifestations,combined with characteristic MRI findings,are crucial in diagnosing PRES among organ transplant recipients.However,when standard treatments are ineffective or MRI results are atypical,alternative diagnoses should be taken into considered.

Tacrolimus-induced posterior reversible encephalopathy syndrome following liver transplantation

In this editorial,we talk about a compelling case focusing on posterior reversible encephalopathy syndrome(PRES)as a complication in patients undergoing liver transplantation and treated with Tacrolimus.Tacrolimus(FK 506),derived from Streptomyces tsukubaensis,is a potent immunosuppressive macrolide.It inhibits Tcell transcription by binding to FK-binding protein,and is able to amplify glucocorticoid and progesterone effects.Tacrolimus effectively prevents allograft rejection in transplant patients but has adverse effects such as Tacrolimus-related PRES.PRES presents with various neurological symptoms alongside elevated blood pressure,and is primarily characterized by vasogenic edema on neuroimaging.While computed tomography detects initial lesions,magnetic resonance imaging,especially the Fluid-Attenuated Inversion Recovery sequence,is superior for diagnosing cortical and subcortical edema.Our discussion centers on the incidence of PRES in solid organ transplant recipients,which ranges between 0.5 to 5+ACU-,with varying presentations,from seizures to visual disturbances.The case of a 66-year-old male status post liver transplantation highlights the diagnostic and management challenges associated with Tacrolimus-related PRES.Radiographically evident in the parietal and occipital lobes,PRES underlines the need for heightened vigilance among healthcare providers.This editorial emphasizes the importance of early recognition,accurate diagnosis,and effective management of PRES to optimize outcomes in liver transplant patients.The case further explores the balance between the efficacy of immunosuppression with Tacrolimus and its potential neurological risks,underlining the necessity for careful monitoring and intervention strategies in this patient population.

Posterior reversible encephalopathy syndrome following uneventful clipping of an unruptured intracranial aneurysm:A case report

BACKGROUND Posterior reversible encephalopathy syndrome(PRES)is characterized mainly by occipital and parietal lobe involvement,which can be reversible within a few days.Herein,we report a rare case of PRES that developed after craniotomy for an unruptured intracranial aneurysm(UIA).CASE SUMMARY A 59-year-old man underwent clipping surgery for the treatment of UIA arising from the left middle cerebral artery.Clipping surgery was performed uneventfully,and he regained consciousness quickly immediately after the surgery.At the 4th hour after surgery,he developed a disorder of consciousness and aphasia.Magnetic resonance imaging revealed cortical and subcortical T2/FLAIR hyperintensities in the parietal,occipital,and frontal lobes ipsilaterally,without restricted diffusion,consistent with unilateral PRES.With conservative treatment,his symptoms and radiological findings almost completely disappeared within weeks.In our case,the important causative factor of PRES was suspected to be a sudden increase in cerebral perfusion pressure associated with temporary M1 occlusion.CONCLUSION Our unique case highlights that,to our knowledge,this is the second report of PRES developing after craniotomy for the treatment of UIA.Surgeons must keep PRES in mind as one of the causes of perioperative neurological abnormality following clipping of an UIA.

Decompressive Craniectomy for Posterior Reversible Encephalopathy Syndrome (PRES): Case Report

Background: Posterior reversible encephalopathy syndrome (PRES) is an uncommon clinical-neuroradiological syndrome with an unclear pathophysiology. Correlation between PRES and the use of immunosuppressant drugs have previously been described, as well as correlation between elevated blood pressure and PRES. Characteristic brain MRI manifestations include hyperintense lesions on T2 and FLAIR (fluid-attenuated inversion recovery) images. PRES is usually reversible within a short period of time after discontinuation of the presumably offending drug. Some cases of PRES might complicate with intracranial hemorrhage, refractory status epilepticus or expansive vasogenic brain edema (also regarded as “tumefactive” PRES). Methods: We present a case of a young man diagnosed with Hodgkin’s lymphoma, following a laparotomy due to cecal volvulus. The patient received glucocorticoids and elevated blood pressure values were recorded. Brain imaging studies were performed due to generalized epileptic seizures, demonstrating neuroradiological findings consistent with PRES. Neurological and neuroradiological deterioration was noted, necessitating urgent neurosurgical intervention. A complete neurological and functional rehabilitation was achieved. Conclusion: The uncommon cases of complicated PRES should be taken under consideration whenever clinical deterioration is noted following the diagnosis of PRES. Early neuroradiological evaluation should be sought, together with aggressive medical and surgical treatment in cases of life threatening mass effect.

Postpartum posterior reversible encephalopathy syndrome secondary to preeclampsia and cerebrospinal fluid leakage:A case report and literature review

BACKGROUND Postpartum posterior reversible encephalopathy syndrome(PRES) is not uncommon.Its mechanisms and risk factors are not clear.CASE SUMMARY A 28-year-old woman underwent cesarean section but had inadvertent dural puncture during epidural anesthesia.To manage the symptoms of intracranial hypotension,crystalloid fluid was infused.However,the patient developed postpartum preeclampsia and PRES.The patient was treated with diazepam and dehydration therapy.The signs of cerebral lesions on magnetic resonance imaging disappeared on postpartum day 7.CONCLUSION Postpartum preeclampsia and PRES can develop concomitantly.Treating postdural puncture headaches with infusion of crystalloid fluid may precipitate the development of PRES.

Posterior reversible encephalopathy syndrome in a patient with metastatic breast cancer:A case report

BACKGROUND Posterior reversible encephalopathy syndrome(PRES)is a neurotoxic encephalopathic state with clinical symptoms such as headache,altered consciousness,visual disturbances,and seizures.Vasogenic edema occurs predominantly in the posterior occipital and parietal lobes of the brain.PRES is caused by various diseases,and its mechanism remains unclear.However,it can be easily diagnosed based on characteristic lesions on magnetic resonance imaging.CASE SUMMARY A 51-year-old woman with unremarkable past medical history presented with progressively worsening back pain since 2 mo.Physical examinations revealed paralumbar muscle tenderness,a large lesion on the right breast and several masslike lesions on both breasts.The blood pressure(BP)was elevated(150/90 mmHg),and did not respond to antihypertensive medication.On the seventh day of hospitalization,she exhibited a confused mental status and generalized tonicclonic seizures.On magnetic resonance imaging,bilateral cortical and subcortical edema of the occipital lobes,suggestive of PRES,was observed.The serum calcium was 15.8 mg/dL.After two days of treatment with nicardipine,elcatonin,and zolendronic acid,her BP was 130/91 mmHg and serum calcium was 10.1 mg/dL.The patient regained consciousness and her mental status improved.Fluorodeoxyglucose-positron emission tomography revealed right breast cancer with extensive metastases.CONCLUSION Although rare,hypercalcemia can lead to PRES by causing uncontrolled hypertension.Prompt diagnosis can help prevent severe mental disturbances and even death.

Posterior reversible encephalopathy syndrome and heart failure tacrolimus-induced after liver transplantation: A case report

BACKGROUND Patients undergoing liver transplantation can develop posterior reversible encephalopathy syndrome(PRES)and acute heart failure(HF)in the postoperative period.But PRES with HF caused by tacrolimus has rarely been described.CASE SUMMAR A 40-year-old female patient who had a normal preoperative cardiac and neural evaluation developed PRES with acute heart failure tacrolimus-induced after liver transplantation.The challenges associated with both diagnosis and management in the setting of a newly implanted graft are discussed.CONCLUSION Tacrolimus can induce neurotoxicity and then cardiac toxicity.Magnetic resonance imaging,echocardiography,and increased brain natriuretic peptide may be predictive of post-operative PRES with acute heart failure.Further investigations are necessary to verify this finding.

Posterior reversible encephalopathy syndrome induced after blood transfusion for severe anemia

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headache, confusion, seizures, and cortical visual loss, as well as subcortical edema without infarction on neuroimaging. We report a 56-year-old woman who developed typical manifestations of PRES, 6 days after blood transfusion for severe anemia. Acute volume overloads by transfusion may exceed the capacity of autoregulation of perfusion pressure, possibly resulting in vasogenic edema. We propose that it is clinically important to recognize that rapid correction of anemia by blood transfusion may carry the risk of inducing PRES.

Posterior reversible encephalopathy syndrome following sepsis in a Crohn's disease patient: A case report

Posterior reversible encephalopathy syndrome(PRES)is a clinico-ragiological syndrome presenting with neurological symptoms and characteristic radiologic findings.PRES occurs in the setting of various clinical conditions and requires prompt management of the causative factor for a full recovery.This is a case report of a Crohn’s disease patient who developed PRES syndrome during a complicated post-operative course.In the presence of multiple causative factors,sepsis was considered as the predominant one.After prompt management,the patient recovered with no permanent neurological damage.

Posterior reversible encephalopathy syndrome in alcoholic hepatitis:Hepatic encephalopathy a common theme

Posterior reversible encephalopathy syndrome(PRES) is a neuro-radiologic diagnosis that has become more widely recognized and reported over the past few decades. As such, there are a number of known risk factors that contribute to the development of this syndrome, including volatile blood pressures, renal failure, cytotoxic drugs, autoimmune disorders, pre-eclampsia, and eclampsia. This report documents the first reported case of PRES in a patient with severe alcoholic hepatitis with hepatic encephalopathy and delves into a molecular pathophysiology of the syndrome.

Autoimmune encephalitis with posterior reversible encephalopathy syndrome:A case report

BACKGROUND Posterior reversible encephalopathy syndrome(PRES)is a neuroimaging-based syndrome and is associated with multifocal vasogenic cerebral edema.Patients with PRES frequently demonstrate headache,seizure,encephalopathy,altered mental function,visual loss and so on.We here report a patient who showed persistent neurologic deficits after PRES and was ultimately diagnosed with autoimmune encephalitis(AE).CASE SUMMARY This case exhibits a rare imaging manifestation of anti-casper 2 encephalitis which was initially well-matched with PRES and associated vasogenic edema.CONCLUSION AE should be further considered when the etiology,clinical manifestations,and course of PRES are atypical.

Comment on “Posterior reversible encephalopathy syndrome in a patient with metastatic breast cancer: A case report”

Posterior reversible encephalopathy syndrome(PRES)is a neurotoxic encephalopathic state,manifesting clinical symptoms of headache,altered consciousness,visual disturbances,and seizures.Although several diseases have been identified as causative of PRES,the underlying mechanism remains unclear.Song et al recently published“Posterior reversible encephalopathy syndrome(PRES)in a patient with metastatic breast cancer:A case report“in the World Journal of Clinical Cases,highlighting and discussing the role of hypercalcemia in PRES as related to uncontrolled hypertension.To build upon this case description,we provide further insight into the possible underlying mechanisms of PRES through this commentary.

Oral cyclophosphamide-induced posterior reversible encephalopathy syndrome in a patient with ANCA-associated vasculitis:A case report

BACKGROUND Posterior reversible encephalopathy syndrome(PRES)manifests many neurological symptoms with typical features on neuroimaging studies and has various risk factors.Cyclophosphamide is one of the therapeutic agents for antineutrophil cytoplasmic antibody(ANCA)-associated vasculitis.Cyclophosphamide as the sole cause of PRES has been reported in only a few cases.Herein,we report a unique case of early-onset oral cyclophosphamide-induced PRES in a patient with ANCA-associated vasculitis.CASE SUMMARY A 73-year-old man was transferred to our hospital for sepsis due to acute cholangitis.He had already received hemodialysis for two weeks due to septic acute kidney injury.His azotemia was not improved after sepsis resolved and perinuclear-ANCA was positive.Kidney biopsy showed crescentic glomerulonephritis.Alveolar hemorrhage was observed on bronchoscopy.He was initially treated with intravenous methylprednisolone and plasma exchange for one week.And then,two days after adding oral cyclophosphamide,the patient developed generalized tonic-clonic seizures.We diagnosed PRES by Brain magnetic resonance imaging(MRI)and electroencephalography.Seizures were controlled with fosphenytoin 750 mg.Cyclophosphamide was suspected to be the cause of PRES and withdrawal.His mentality was recovered after seven days and brain MRI showed normal state after two weeks.CONCLUSION The present case shows the possibility of PRES induction due to short-term use of oral cyclophosphamide therapy.Physicians should carefully monitor neurologic symptoms after oral cyclophosphamide administration in elderly patients with underlying diseases like sepsis,renal failure and ANCA-associated vasculitis.

Posterior Reversible Encephalopathy Syndrome Induced by Pazopanib in a Patient with Soft-Tissue Sarcoma: A Case Report

Posterior reversible encephalopathy syndrome (PRES), a rare disease is characterized by multiple neurological complications. It has been reported to be associated with the use of angiogenesis inhibitors such as sorafenib, sunitinib, pazopanib, regorafenib, and lenvatinib. We reported a case of 76-year-old woman with history of stage III hepatocellular carcinoma (HCC), who developed adverse drug reactions related to pazopanib induced PRES. Pazopanib, an angiogenesis inhibitor which inhibits the vascular endothelial growth factor (VEGF) pathway may lead to vascular endothelial damage, and these pathophysiological changes may lead to vascular leaks and brain edema. Medical staff must be aware of the possible association between angiogenesis inhibitors and the development of PRES. In patients with retroperitoneal soft-tissue sarcoma undergoing treatment with pazopanib, regular monitoring of their blood pressure and following-up brain magnetic resonance imaging (MRI) should be encouraged.

A Typical Case of Posterior Reversible Encephalopathy Syndrome Associated with Postpartum Eclampsia-HELLP Syndrome

Background: Posterior reversible encephalopathy syndrome (PRES) is a reversible syndrome characterized by seizures, headache, altered mentation, and loss of vision associated with white matter changes on imaging. Case: A 37-year-old multigravida woman had a severe, immediate postpartum eclampsia-HELLP syndrome (hemolysis, elevated liver enzyme levels, low platelet count) with PRES characterized by generalized seizures and altered mental status. Magnetic resonance brain imaging showed high-intensity lesions in non-posterior portions including the frontal lobe and cingulated gyrus, which resolved completely after 2 weeks along with complete symptom regression. Conclusions: Cases of postpartum PRES without involvement of posterior brain regions after eclampsia-HELLP syndrome are very rare. Patients with PRES do not always show typical manifestations. The importance of a prompt diagnosis is emphasized, as is the crucial role of rapid blood pressure reduction.

A Case Report of Posterior Reversible Encephalopathy Syndrome with Rapidly Progressive Glomerulonephritis Combined with Membranous Nephropathy

Rapidly progressive glomerulonephritis is a group of clinical syndromes,in which renal function of patient progressively deteriorates with pathological manifestation of extensive glomerular crescent formation.Among which,anti-glomerular basement membrane antibody glomerulonephritis is the rarest but the most aggressive subtype.This paper discusses a case of rapidly progressive glomerulonephritis combined with membranous nephropathy.There were posterior reversible encephalopathy syndromes during diagnosis and treatment.Diagnosis was confirmed in time by laboratory examination and renal pathology.Condition of the patient was alleviated through close work between all departments.This allowed us to further understand the case characteristics of rapidly progressive glomerulonephritis combined with membranous nephropathy,importance of effective prevention,and significance of various complications during treatment,so as to alleviate pain and improve prognosis in patient.

A Delicate Diagnostic of Posterior Reversible Encephalopathy Syndrome (PRES) Revealed by Repetitive Convulsions in a 14-Year-Old Child: A Case Report and Review of the Literature

Background: Rare pathological conditions are frequently a diagnostic challenge in intensive care. Posterior-reversible encephalopathy syndrome (PRES) is a clinical and imaging diagnosis recently individualized. It occurs in various conditions such as collagenosis or vasculitis of the central nervous system, electrolytic disorders and the use of cytotoxics or immunosuppressive treatment. It is responsible for non-specific neurological manifestations such as confusion, coma, convulsions or visual disturbances. The diagnosis is suggested by brain magnetic resonance imaging (MRI). The lesions correspond to vasogenic edema and are therefore generally reversible after etiologic treatment and control of blood pressure. Aim: This clinical case aims to show the diagnostic complexity of rare pathologies in the intensive care unit. Case presentation: We present a case of a 14-year-old child received in the pediatrics department for generalized tonic-clonic convulsions with tongue biting in a febrile context. Malaria was negative, with hyperleukocytosis, slightly elevated C-reactive protein, anemia and hypokliemia, lumbar puncture was performed and all cerebrospinal fluid examinations revealed nothing. The seizures were controlled by titrated cumulative doses of diazepam with a total of 12mg, antibiotic therapy with ceftriaxone, corticotherapy with dexamethasone 12mg and blood transfusion without any improvement in his condition. He was then transferred to intensive care where the clinical and paraclinical assessment highlighted a neurological deficit Glasgow coma scale of 12/15 and biological hyponatremia. Brain CT-scan was normal. Hydroelectrolytic equilibration was undertaken, antibiotics continued, anti-comital prophylaxis and general resuscitation measures were provided. He regained consciousness on the 3rd day. On the 4th day, he presented high blood pressure and on the 5th, a resumption of convulsions without any obvious biological disorder, cerebrospinal fluid control was once more non-pathological. An MRI was performed and revealed Posterior-reversible encephalopathy syndrome. Conclusion: Posterior-reversible encephalopathy syndrome is a rare disease. It is necessary to keep rare diseases in mind.

脑后部可逆性脑病综合征(PRES)的临床MR诊断

目的探讨MR对PRES的临床诊断价值。方法应用3.0 T MR对30例PRES患者进行常规扫描,其中19例同时行MRA检查,13例行MRV检查。结果 PRES病变主要累及顶枕叶,双侧基本对称;病变主要位于脑白质内,也可累及其它部位。PRES病变的特点是呈长T1长T2信号,边缘不清,无明显占位效应。MRA及MRV均无异常发现。结论 MR对PRES可以作出准确诊断,对临床有重要的指导意义。

Posterior reversible encephalopathy syndrome in patients with hematologic tumor confers worse outcome

Background:This study aimed to evaluate the clinical features of posterior reversible encephalopathy syndrome(PRES)in children.Methods:The medical records of 31 patients from five medical centers who were diagnosed with PRES from 2001 to 2013 were retrospectively analyzed.In the 31 patients,16 were males,and 15 females,with a median age of 7 years(3-12 years).Patients younger than 10 years accounted for 74.2%of the 31 patients.Results:Seizure,the most common clinical sign,occurred in 29 of the 31 patients.Visual disturbances were also observed in 20 patients.Cerebral imaging abnormalities were bilateral and predominant in the parietal and occipital white matter.In this series,three patients died in the acute phase of PRES.One patient had resolution of neurologic presentation within one week,but no apparent improvement in radiological abnormalities was observed at eight months.One patient showed gradual recovery of both neurologic presentation and radiological abnormalities during follow-up at eight months.One patient developed long-term cortical blindness.All of the PRES patients with hematologic tumor had a worse prognosis than those without hematologic tumor.Conclusions:Seizure is a prevalent characteristic of children with PRES.Poor prognosis can be seen in PRES patients with hematologic tumor.

孤立脑干受累PRES合并皮质下梗死4 例报告及文献回顾分析

可逆性后部脑病综合征(posterior reversible encephalopathy syndrome,PRES)是一种临床影像综合征,从急性到亚急性起病,其临床表现主要包括头痛、视觉异常、癫痫发作、意识及精神障碍等,特征影像表现为顶枕叶对称性血管源性水肿,通常发生在高血压危象、子痫前期/子痫、肾功能受损和免疫抑制治疗中[1]。随着对这一疾病认识的增加,临床和放射学特征的范围被认为比最初描述的要广泛得多,血管源性水肿并不总是位于后部,病灶可以是不可逆的[2],尤其是一些不常见的影像学特征,如孤立的后颅窝(脑干和或小脑)受累、弥散受限和颅内出血。PRES仅孤立的累及幕下结构,没有相关的典型顶枕叶病变,称之为中央变异型PRES[3]、孤立脑干/幕下受累PRES[4]或高血压脑干脑病[5],是罕见的,既往文献报道,在所有PRES类型中不足4%[6]。孤立脑干受累PRES易被误诊,导致不必要的辅助检查或治疗,虽多数预后良好,但对于合并梗死和(或)出血往往预后不良。为进一步加强对本病的认识,回顾分析2018年6月-2021年11月我科收治的4例孤立脑干受累PRES合并皮质下梗死的临床及影像特征,并进行相关文献回顾,旨在为本病早期诊断和及时治疗提供依据。