Cyclosporine-related posterior reversible encephalopathy syndrome (PRES) in non-transplant patient: a case report and literature review

Treatment of Juvenile Dermatomyositis: An Update

The idiopathic inflammatory myopathies of childhood consist of a heterogeneous group of autoimmune diseases characterised by proximal muscle weakness and pathognomonic skin rashes. The overall prognosis of juvenile myositis has improved significantly over recent years, but the long-term outcome differs substantially from patient to patient, suggestive of distinct clinical phenotypes with variable responses to treatment. High doses of corticosteroids remain the cornerstone of therapy along with other immunosuppressant therapies depending on disease severity and response. The advent of biological drugs has revolutionised the management of various paediatric rheumatologic diseases, including inflammatory myopathies. There are few data from randomised controlled trials to guide management decisions; thus, several algorithms for the treatment of juvenile myositis have been developed using international expert opinion. The general treatment goals now include elimination of active disease and normalisation of physical function, so as to preserve normal growth and development, and to prevent long-term damage and deformities. This review summarises the newer and possible future therapies of juvenile inflammatory myopathies, including evidence supporting their efficacy and safety.

Posterior Reversible Encephalopathy Syndrome in Early Postpartum Woman

There have been reports about posterior reversible encephalopathy syndrome (PRES) associated with pregnancy, especially peripartum. However, the pathophysiology of PRES is not still clear. Tonic-clonic seizure occurred during early postpartum in a woman with the tendency toward pre-eclampsia developed after vaginal delivery followed by emergency cesarean hysterectomy. Postictal findings included headache, loss of vision, and short-term memory loss and magnetic resonance imaging (MRI) findings suggesting PRES were noted. Neurologic symptoms and cerebral lesions were gradually improved with immediate supportive managements.

Postictal cortical visual impairment: a symptom of posterior reversible encephalopathy

We describe a patient presenting with a first generalized convulsion after alcohol consumption, in whom the early postictal finding of a rapidly regressive cortical visual impairment suggested the presence of a posterior reversible encephalopathy. This was confirmed radiologically, and probably represented the key factor in the seizure etiology.

Lysergic acid amide-induced posterior reversible encephalopathy syndrome with status epilepticus

INTRODUCTION

Posterior reversible encephalopathy syndrome (PRES) is known to occur in association with several substances. However, lysergic acid amide (LSA) is not among the previously reported causes of PRES.

METHODS

We report on a patient with PRES presenting as convulsive status epilepticus associated with hypertensive encephalopathy after LSA ingestion. Magnetic resonance imaging was performed and catecholamine metabolites assayed.

RESULTS

The patient achieved a full recovery after aggressive antihypertensive therapy and intravenous anticonvulsivant therapy. The clinical history, blood and urinary catecholamine levels, and response to treatment strongly suggest that PRES was induced by LSA.

CONCLUSION

LSA, a hallucinogenic agent chiefly used for recreational purposes, should be added to the list of causes of PRES.

Imaging for neuro-ophthalmic and orbital disease - a review

A literature review was performed by content experts in neuro-ophthalmology and neuroradiology using a systematic English-language Medline search (1994-2008) limited to articles with relevance to neuro-ophthalmic and orbital imaging. The information covered in this review includes: (i) the basic mechanics, indications and contraindications for cranial and orbital computed tomography and magnetic resonance (MR) imaging; (ii) the utility and indications for intravenous contrast, (iii) the use of specific MR sequences; (iv) the techniques and ophthalmic indications for computed tomography/MR angiography and venography; and (v) the techniques and indications for functional MR imaging, positron emission tomography scanning and single photon emission computed tomography. Throughout the review accurate and timely communication with the neuroradiologist regarding the clinical findings and suspected location of lesions is emphasized so as to optimize the ordering and interpretation of imaging studies for the ophthalmologist.

Two cases of progressive multifocal leukoencephalopathy after allogeneic hematopoietic cell transplantation and a review of the literature

Progressive multifocal leukoencephalopathy (PML) is a rare subacute demyelinating disorder of the central nervous system (CNS) caused by the DNA JC human polyomavirus. In immunocompromised hosts, PML is caused by reactivation of a latent infection rather than de novo primary exposure. PML in the setting of hematopoietic cell transplantation (HCT) is exceedingly rare. PML should be considered in the differential diagnosis of HCT recipients, autologous or allogeneic, presenting with worsening of neurological symptoms, especially associated with post-transplant neurodegenerative findings. Although DNA polymerase chain reaction (PCR) of the cerebrospinal fluid (CSF) has emerged as a promising tool for detecting JC virus, a negative result does not rule out PML. Brain biopsy remains the most reliable and accurate method for diagnosing JC virus-associated PML. Presently, there is no universally effective antiviral therapy against JC virus and outcome is fatal in the majority of cases. We hereby describe two cases of PML developing after allogeneic HCT and provide a comprehensive review of the literature.

Upward transtentorial herniation, hydrocephalus, and cerebellar edema in hypertensive encephalopathy

BACKGROUND

Edema of the cerebellum with secondary obstructive hydrocephalus is a rare presentation of hypertensive encephalopathy. The authors report an unusual case of isolated posterior fossa swelling with upward transtentorial herniation and hydrocephalus causing neurologic deterioration. These patients are often initially evaluated by a neurologist because of the acute neurologic symptoms. Prompt diagnosis with aggressive blood pressure control may obviate the need for emergent cerebrospinal fluid (CSF) diversion.

REVIEW SUMMARY

This is a case report of a 26-year-old man who presented to the emergency room with confusion and somnolence over a 2-day period. His initial blood pressure was 175/110 mmHg. On examination he was disoriented, with a Glasgow Coma Scale score of 12 points, opening his eyes only to loud verbal stimuli, verbalizing inappropriately, and he was only able to follow simple commands. Neuroimaging revealed edema of the cerebellar folia with noncommunicating hydrocephalus and upward transtentorial herniation. Differential diagnoses of posterior fossa tumor, rhombencephalitis, and hypertensive encephalopathy were entertained. A thorough literature review is included with the discussion of this case. The patient underwent emergent ventriculostomy for CSF drainage and prompt blood pressure control with nitroprusside. After 48 hours of CSF drainage and correction of his hypertension, his neurologic examination normalized. Repeat imaging revealed near resolution of the obstructive hydrocephalus and cerebellar edema.

CONCLUSION

Isolated edema of the cerebellum with upward transtentorial herniation and obstructive hydrocephalus is a rare presentation of hypertensive encephalopathy and should be considered in patients with an acute hypertensive crisis and mental status changes. This entity responds to prompt blood pressure control; however, emergent ventriculostomy by a neurosurgical team should be entertained for neurologic deterioration secondary to significant obstructive hydrocephalus, as illustrated in this case.

Persistent Visual Loss After Retinochoroidal Infarction in Pregnancy-Induced Hypertension and Disseminated Intravascular Coagulation

A 40-year-old woman had pregnancy-induced hypertension, disseminated intravascular coagulation (DIC), choroidal infarction, and magnetic resonance imaging (MRI) high-signal abnormalities in the occipital regions. With successful treatment of the hypertension and spontaneous resolution of the DIC, the MRI signal abnormalities resolved, but visual acuity remained decreased because of damage to the retina and choroid. This case demonstrates that pregnancy-induced hypertension, particularly if combined with DIC, may produce infarction of the retina and choroid and persistent visual loss even if the effect of this condition on the occipital lobes is limited to reversible vasogenic edema.

Implications of post-gadolinium MRI results in 13 cases with posterior reversible encephalopathy syndrome

BACKGROUND

There is a relative lack of definitive information about the contrast-enhancement characteristics of lesions in posterior reversible encephalopathy syndrome (PRES).

OBJECTIVE

Evaluation of contrast-enhanced MRI findings in PRES with a special emphasis on pathophysiology of post-gadolinium behavior of these lesions.

MATERIALS AND METHODS

Contrast-enhanced 1.5 T MRI findings and relevant clinical data of the patients were retrospectively reviewed on 13 cases (six males, seven females; age range: 22-78; mean age 47). Although fluid attenuated inversion recovery (FLAIR) and diffusion-weighted MR images were considered for identification of the entity, primarily post-contrast T1-weighted MR images were searched for traces of enhancement in the lesions.

RESULTS

No definitely enhancing lesion was identified in the MR images obtained in 6-48 h after onset of symptoms (mostly headaches, seizures and cortical visual field deficits) in this series. Severity of disease indicated by small hemorrhages, confluence of lesions or progression to cytotoxic edema did not seem to alter this result. Typical lesion characteristics were consistent with vasogenic edema on FLAIR and diffusion MR images. Acute elevation of blood pressure on chronic hypertensive background was responsible in four, eclampsia in three, uremia with blood pressure fluctuations in three, and cyclosporine-toxicity in three cases.

CONCLUSION

Although occasional enhancing brain lesions have been reported in the literature on PRES, contrast-enhancement of lesions may be a factor of scan timing and underlying etiology. Prospective studies with larger series on PRES are required for better evaluation of contrast-enhancement in MRI with respect to scan timing, which in turn may help understand its pathophysiology better.

Reversible encephalopathy syndrome: report of 12 cases with follow-up

We report the clinical and neuroradiological features of reversible encephalopathy syndrome and follow-up results in 12 patients. This syndrome seems to be the result of an acute encephalopathy showing with brain edema mainly in the white matter (vasogenic edema). Diffusion-weighted magnetic resonance images are useful to distinguish this entity from acute ischemia. Early recognition and treatment often lead to complete neurological recovery. If unrecognized, the patient's condition can progress to central nervous system failure.