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Liu Y, Li Q, Liu Y, Qiao P, Liu S, Xu K. The challenging clinical dilemma of posterior reversible encephalopathy syndrome in systemic lupus erythematosus. Z Rheumatol 2024; 83:124-131. [PMID: 37405426 DOI: 10.1007/s00393-023-01385-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Posterior reversible encephalopathy syndrome (PRES) in systemic lupus erythematosus (SLE) is a challenging clinical dilemma. A retrospective single-center study was performed to investigate the clinical features, risk factors, outcomes, and clinical determinants of the prognosis of PRES in SLE. METHODS A retrospective study was performed from January 2015 to December 2020. 19 episodes of lupus PRES and 19 episodes of non-lupus PRES were identified. 38 cases of patients presenting with neuropsychiatric lupus (NPSLE) hospitalized during the same period were selected as controls. Survival status was acquired via outpatient and telephone follow-up in December 2022. RESULTS The clinical neurological presentation of PRES in lupus patients was similar to that of the non-SLE-related PRES and NPSLE populations. Nephritis-induced hypertension is the predominant trigger of PRES in SLE. Disease flare and renal failure-triggered PRES were identified in half of the patients with SLE. The mortality rate of lupus-related PRES during the 2‑year follow-up was 15.8%, the same as that of NPSLE. For patients with lupus-related PRES, multivariate analysis indicated that high diastolic blood pressure (OR =1.762, 95% CI: 1.031 ~ 3.012, p = 0.038), renal involvement (OR = 3.456, 95% CI: 0.894 ~ 14.012, p = 0.049), and positive proteinuria (OR = 1.231, 95% CI: 1.003 ~ 1.511, p = 0.047) were independent risk factors compared to NPSLE. A strong connection between the absolute counts of T and/or B cells and prognosis in lupus patients with neurological manifestations was found (p < 0.05). The lower the counts of T and/or B cells, the worse the prognosis. CONCLUSION Lupus patients with renal involvement and disease activity are more likely to develop PRES. The mortality rate of lupus-related PRES is similar to that of NPSLE. Focusing on immune balance might reduce mortality.
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Affiliation(s)
- Yang Liu
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, 030032, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Qian Li
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, 030032, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ying Liu
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, 030032, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Pengyan Qiao
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, 030032, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Sumiao Liu
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, 030032, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ke Xu
- Department of Rheumatology and Immunology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, 030032, Taiyuan, China.
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
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Li Y, Song J, Huq AM, Timilsina S, Gershwin ME. Posterior reversible encephalopathy syndrome and autoimmunity. Autoimmun Rev 2023; 22:103239. [PMID: 36464226 DOI: 10.1016/j.autrev.2022.103239] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome characterized by acute or subacute onset of neurological symptoms (e.g., headache, seizure, confusion, vomiting, and diminished eyesight) and impaired endothelial barrier function of the cerebral circulation that leads to bilateral subcortical vasogenic edema, while exhibiting a "reversible" feature in most cases. Clinically, various predisposing or precipitating conditions have been identified, such as hypertension, autoimmune diseases, renal dysfunction/failure, preeclampsia/eclampsia, post-transplantation conditions, and certain therapeutic agents. Among several putative mechanisms, the immune activation hypothesis prevails, as up to 50% of patients with PRES harbor abnormalities related to autoimmunity, such as concurrent systemic lupus erythematosus. In this Review, we summarize the clinical and laboratory evidence that places PRES in the context of autoimmunity.
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Affiliation(s)
- Yang Li
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China
| | - Junmin Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China.
| | - Ahm M Huq
- Department of Pediatrics, Central Michigan University, Detroit, MI 48201, USA
| | - Suraj Timilsina
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616, USA
| | - M Eric Gershwin
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616, USA
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3
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Shadmani G, Simkins TJ, Assadsangabi R, Apperson M, Hacein-Bey L, Raslan O, Ivanovic V. Autoimmune diseases of the brain, imaging and clinical review. Neuroradiol J 2022; 35:152-169. [PMID: 34490814 PMCID: PMC9130615 DOI: 10.1177/19714009211042879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is an extensive spectrum of autoimmune entities that can involve the central nervous system, which has expanded with the emergence of new imaging modalities and several clinicopathologic entities. Clinical presentation is usually non-specific, and imaging has a critical role in the workup of these diseases. Immune-mediated diseases of the brain are not common in daily practice for radiologists and, except for a few of them such as multiple sclerosis, there is a vague understanding about differentiating them from each other based on the radiological findings. In this review, we aim to provide a practical diagnostic approach based on the unique radiological findings for each disease. We hope our diagnostic approach will help radiologists expand their basic understanding of the discussed disease entities and narrow the differential diagnosis in specific clinical scenarios. An understanding of unique imaging features of these disorders, along with laboratory evaluation, may enable clinicians to decrease the need for tissue biopsy.
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Affiliation(s)
- Ghazal Shadmani
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
| | - Tyrell J Simkins
- Department of Neurology
(Neuroimmunulogy), University of California Davis Medical center, USA
| | - Reza Assadsangabi
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
| | - Michelle Apperson
- Department of Neurology
(Neuroimmunulogy), University of California Davis Medical center, USA
| | - Lotfi Hacein-Bey
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
| | - Osama Raslan
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of
Neuroradiology, University of California Davis Medical Center, USA
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4
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Kausha M, Vishal S, Kondekar Alpana S. Posterior reversible encephalopathy syndrome in a known case of sickle-beta-thalassemia: a case presentation. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-022-00122-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Posterior reversible encephalopathy syndrome is a reversible condition, which occurs in response to acute changes in blood pressure due to failure of posterior circulatory autoregulation. Posterior reversible encephalopathy syndrome in sickle cell patients has been rarely reported previously in the setting of severe crisis or uncontrolled hypertension.
Case presentation
We report a very rare case of posterior reversible encephalopathy syndrome that occurred in a 10-year-old male child with sickle-beta-thalassemia which was detected at 4 years of age and required 2 units of packed red blood cells transfusion in last 6 years. At the time of the presentation, he was hypertensive with blood pressure 140/100 mm of Hg (> 99th percentile) and had focal seizures with magnetic resonance imaging findings suggestive of posterior reversible encephalopathy syndrome. Patient was treated with anticonvulsant and antihypertensives and had complete recovery of symptoms.
Conclusions
Posterior reversible encephalopathy syndrome is a rare neurological presentation in a sickle-beta thalassemia; this case guides in differentiating it from other common neurological manifestations in sickel-beta thalassemia and emphasis on early management as it is completely reversible.
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5
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Manadan A, Kambhatla S, Gauto-Mariotti E, Okoli C, Block JA. Rheumatic Diseases Associated With Posterior Reversible Encephalopathy Syndrome. J Clin Rheumatol 2021; 27:e391-e394. [PMID: 32604240 DOI: 10.1097/rhu.0000000000001470] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Posterior reversible encephalopathy syndrome (PRES) is an acute neurological syndrome. There are many reports of PRES occurring in the setting of rheumatic diseases. However, it remains uncertain whether rheumatic diseases are truly a risk factor for PRES, as the literature consists of case reports and small clinical series. Here, we evaluated the relationship between PRES and the rheumatic diseases, using a large population-based data set as the reference. METHODS We conducted a medical records review of hospitalizations in the United States during 2016 with a diagnosis of PRES. Hospitalizations were selected from the National Inpatient Sample. International Classification of Diseases, 10th Revision, Clinical Modification codes were used to identify rheumatic diseases. A multivariate logistic regression analysis was used to calculate odds ratios (ORs) for the association of PRES and rheumatic diseases. RESULTS There were 3125 hospitalizations that had a principal billing diagnosis of PRES. Multivariate logistic regression revealed the multiple independent associations with PRES. The demographic and nonrheumatic associations included acute renal failure (OR, 1.52), chronic renal failure (OR, 12.1), female (OR, 2.28), hypertension (OR, 8.73), kidney transplant (OR, 1.97), and preeclampsia/eclampsia (OR, 11.45). Rheumatic associations with PRES included antineutrophil cytoplasmic antibody-associated vasculitis (OR, 9.31), psoriatic arthritis (OR, 4.61), systemic sclerosis (OR, 6.62), systemic lupus erythematosus (SLE) nephritis (OR, 7.53), and SLE without nephritis (OR, 2.38). CONCLUSIONS This analysis represents the largest sample to date to assess PRES hospitalizations. It confirms that several rheumatic diseases are associated with PRES, including antineutrophil cytoplasmic antibody-associated vasculitis, systemic sclerosis, SLE, and psoriatic arthritis. Acute and unexplained central nervous system symptoms in these patient populations should prompt consideration of PRES.
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Affiliation(s)
| | | | | | - Chimuanya Okoli
- From the Division of Rheumatology, Rush University Medical Center
| | - Joel A Block
- From the Division of Rheumatology, Rush University Medical Center
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6
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Islam R, Das S, Chattopadhyay S, Basu S. Neuropsychiatric lupus with posterior reversible encephalopathy syndrome: a rare presentation. BMJ Case Rep 2021; 14:e241494. [PMID: 34135075 PMCID: PMC8211072 DOI: 10.1136/bcr-2020-241494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2021] [Indexed: 11/03/2022] Open
Abstract
Systemic lupus erythematosus presenting with neuropsychiatric symptoms (NPSLE) along with posterior reversible encephalopathy syndrome (PRES) is rare. A young woman of 29 years presented with various neuropsychiatric symptoms along with low-grade fever, occasional headache, skin rash, arthralgias and gradually became non-ambulatory over last 6 months. After admission, she had an episode of generalised tonic-clonic seizure, followed by drowsiness. She was normotensive. Investigations revealed no evidence of any underlying infection, normal renal functions and electrolytes; but other parameters were supportive to a diagnosis of NPSLE. MRI brain showed vasogenic oedema characterised by symmetrical hyperintensities over posterior brain regions in T2 and fluid attenuated inversion recovery images with no restricted diffusion in diffusion weighted image suggestive of PRES. A diagnosis of NPSLE presenting with PRES, particularly in the absence of hypertension and abnormal renal functions was made, which is a rare presentation. She responded well to immunomodulatory therapy with methylprednisolone and monthly cyclophosphamide.
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Affiliation(s)
- Ramiz Islam
- Internal Medicine, KPC Medical College and Hospital, Jadavpur, West Bengal, India
| | - Sayonee Das
- Internal Medicine, KPC Medical College and Hospital, Jadavpur, West Bengal, India
| | | | - Sagar Basu
- Neurology, KPC Medical College and Hospital, Jadavpur, West Bengal, India
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7
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Silvagni E, Chessa E, Bergossi F, D'Amico ME, Furini F, Guerrini G, Cauli A, Scirè CA, Bertsias G, Govoni M, Piga M, Bortoluzzi A. Relevant domains and outcome measurement instruments in Neuropsychiatric Systemic Lupus Erythematosus: a systematic literature review. Rheumatology (Oxford) 2021; 61:8-23. [PMID: 33788917 DOI: 10.1093/rheumatology/keab324] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Although neuropsychiatric involvement in Systemic Lupus Erythematosus (NPSLE) is one of the most complex and troubling manifestations of the disease, validated outcome instruments to be used as sensitive endpoints in controlled clinical trials are lacking. We set out a systematic literature review (SLR) to identify outcome measurement instruments and domains used to assess NPSLE. METHODS The Preferred Reporting Items for systematic reviews and Meta-analysis (PRISMA) guidelines were used. Articles available in English (1967-2020), listed in PubMed, EMBASE, PsycINFO, Cochrane Library and EULAR outcome measures library were screened. All domains and outcome measurement instruments were characterized according to the OMERACT Filter 2.1, considering core areas (manifestations/abnormalities, life impact, death/lifespan, societal/resource use) and contextual factors. RESULTS Of 3,392 abstracts evaluated, 83 studies were included in the SLR (15,974 patients, females 89.9%). Eligible studies included domains and instruments pertinent to all core areas defined by OMERACT, except for "societal/resource use". The most common core areas were "manifestations/abnormalities", covering 10 domains pertinent to laboratory and instrumental markers, indexes and neuropsychiatric dimension (cognitive, neurologic and psychiatric field), and "life impact", covering 7 domains related to physical function (from both the perspective of the patient and the physician), pain and quality of life. CONCLUSION Our study revealed great heterogeneity in the instruments derived from populations with NPSLE and none of these had high-quality evidence. This supports the need to develop and further validate a core domain set and outcome measurement instruments to promote clinical research in this field, enhancing comparability across studies.
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Affiliation(s)
- Ettore Silvagni
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
| | - Elisabetta Chessa
- Rheumatology Unit, University Clinic and Azienda Ospedaliero-Universitaria of Cagliari, Cagliari (CA), Italy
| | - Francesca Bergossi
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
| | - Maria Ester D'Amico
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
| | - Federica Furini
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy.,Rheumatology Unit, Maggiore Hospital AUSL, Bologna, Italy
| | - Giulio Guerrini
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy.,Internal Medicine, State Hospital, Borgo Maggiore, Republic of San Marino
| | - Alberto Cauli
- Rheumatology Unit, University Clinic and Azienda Ospedaliero-Universitaria of Cagliari, Cagliari (CA), Italy
| | - Carlo Alberto Scirè
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy.,Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy Unit, University of Crete, Heraklion, Greece
| | - Marcello Govoni
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
| | - Matteo Piga
- Rheumatology Unit, University Clinic and Azienda Ospedaliero-Universitaria of Cagliari, Cagliari (CA), Italy
| | - Alessandra Bortoluzzi
- Department of Medical Sciences, Rheumatology Unit, University of Ferrara and Azienda Ospedaliero-Universitaria S. Anna, Cona (Ferrara), Italy
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8
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Gewirtz AN, Gao V, Parauda SC, Robbins MS. Posterior Reversible Encephalopathy Syndrome. Curr Pain Headache Rep 2021; 25:19. [PMID: 33630183 PMCID: PMC7905767 DOI: 10.1007/s11916-020-00932-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 12/11/2022]
Abstract
Purpose of Review This review provides an updated discussion on the clinical presentation, diagnosis and radiographic features, mechanisms, associations and epidemiology, treatment, and prognosis of posterior reversible encephalopathy syndrome (PRES). Headache is common in PRES, though headache associated with PRES was not identified as a separate entity in the 2018 International Classification of Headache Disorders. Here, we review the relevant literature and suggest criteria for consideration of its inclusion. Recent Findings COVID-19 has been identified as a potential risk factor for PRES, with a prevalence of 1–4% in patients with SARS-CoV-2 infection undergoing neuroimaging, thus making a discussion of its identification and treatment particularly timely given the ongoing global pandemic at the time of this writing. Summary PRES is a neuro-clinical syndrome with specific imaging findings. The clinical manifestations of PRES include headache, seizures, encephalopathy, visual disturbances, and focal neurologic deficits. Associations with PRES include renal failure, preeclampsia and eclampsia, autoimmune conditions, and immunosuppression. PRES is theorized to be a syndrome of disordered autoregulation and endothelial dysfunction resulting in preferential hyperperfusion of the posterior circulation. Treatment typically focuses on treating the underlying cause and removal of the offending agents.
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Affiliation(s)
- Alexandra N Gewirtz
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA.
| | - Virginia Gao
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
| | - Sarah C Parauda
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
| | - Matthew S Robbins
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA
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Valdez-López M, Aguirre-Aguilar E, Valdés-Ferrer SI, Martínez-Carrillo FM, Arauz A, Barrera-Vargas A, Merayo-Chalico J. Posterior reversible encephalopathy syndrome: A neuropsychiatric manifestation of systemic lupus erythematosus. Autoimmun Rev 2020; 20:102739. [PMID: 33326853 DOI: 10.1016/j.autrev.2020.102739] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 08/18/2020] [Indexed: 12/29/2022]
Abstract
Posterior Reversible Encephalopathy Syndrome (PRES) is an acute neurological syndrome clinically characterized by seizures, altered mental status, headache, and visual disturbances. It is caused by a variety of abnormalities in the endothelial function that ultimately result in vasogenic edema in the circulation of the central nervous system. This is reflected by the neuroimaging findings, that most often show reversible parieto-occipital edema. An important proportion of patients with PRES present with Systemic Lupus Erythematosus (SLE), and its complications, as their sole risk factors. This review describes the relationship between these two clinical entities and explains the pathophysiological models that have been proposed to describe the development of PRES. We explain how SLE can cause alterations in every pathway implicated in the development of PRES. Given the relatively high frequency and the distinct clinical course, PRES in the setting of SLE might be best described as a distinct neuropsychiatric syndrome associated with SLE.
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Affiliation(s)
- Martín Valdez-López
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Eduardo Aguirre-Aguilar
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Sergio Iván Valdés-Ferrer
- Departmento of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Francisco M Martínez-Carrillo
- Departmento of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suarez", Mexico City, Mexico
| | - Ana Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico.
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Mok CC. Response to: ‘Correspondence on ‘Long-term outcome of a randomised controlled trial comparing tacrolimus with mycophenolate mofetil as induction therapy for active lupus nephritis’’ by Xu. Ann Rheum Dis 2020; 81:e247. [DOI: 10.1136/annrheumdis-2020-219087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/04/2022]
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11
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Hartman EN, Tuna K, Monsour E, Komanduri K, Tarasiuk-Rusek A. Seizure as an Initial Presentation for Posterior Reversible Encephalopathy Syndrome in Undiagnosed Systemic Lupus Erythematosus and Lupus Nephritis: A Case Report. Cureus 2020; 12:e10195. [PMID: 33033673 PMCID: PMC7532865 DOI: 10.7759/cureus.10195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a syndrome presenting with neurological manifestations including headaches, seizures, and notable changes in brain imaging. It is typically associated with an acute increase in blood pressure, metabolic abnormalities, and/or medication effects. PRES is challenging to diagnose due to its variable presentation and low incidence. Herein we describe a compelling case of PRES syndrome secondary to uncontrolled hypertension in the setting of systemic lupus erythematosus (SLE) and lupus nephritis.
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12
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Ulutaş F, Çobankara V, Karasu U, Baser N, Akbudak IH. A Rare Case with Systemic Lupus Erythematosus Manifested by two Different Neurologic Entities; Guillain Barre Syndrome and Posterior Reversible Encephalopathy Syndrome. Mediterr J Rheumatol 2020; 31:358-361. [PMID: 33163871 PMCID: PMC7641029 DOI: 10.31138/mjr.31.3.358] [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: 02/11/2020] [Revised: 05/12/2020] [Accepted: 07/10/2020] [Indexed: 11/07/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an immune-mediated, lifelong disease characterized by quite heterogeneous neuropsychiatric manifestations. Herewith, we report the first rare co-incidental case with posterior reversible encephalopathy syndrome (PRES), Guillain Barre Syndrome (GBS), and (SLE). The coexistence of these neurological conditions in SLE patients could lead to delayed diagnosis and treatment due to this rare coalescence and clinical diversity. Currently, there are no specific, diagnostic radiological or laboratory biomarkers for neurological involvement in SLE. Awareness and, early recognition of neuropsychiatric involvements of the disease are important for timely appropriate treatment. Delayed treatment may cause permanent damage, poor prognosis, long term morbidity, and even death.
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Affiliation(s)
| | | | | | | | - Ismail Hakkı Akbudak
- Department of Intensive Care Unit, Faculty of Medicine, Pamukkale University, Denizli, Turkey
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13
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YILDIRIM-ÇETİN G. Posterior Reversibl Ensefalopati Sendromu: Sistemik Lupus Eritematozuslu hastalarda görülen nadir ve acil klinik bir antite. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2020. [DOI: 10.17517/ksutfd.626090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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14
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Ghali MGZ, Styler MJ. Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1702934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractThe posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.
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Affiliation(s)
- Michael G. Z. Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Michael J. Styler
- Department of Hematology and Oncology, Hahnemann University Hospital, Philadelphia, Pennsylvania, United States
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Chen TH. Childhood Posterior Reversible Encephalopathy Syndrome: Clinicoradiological Characteristics, Managements, and Outcome. Front Pediatr 2020; 8:585. [PMID: 33042923 PMCID: PMC7518237 DOI: 10.3389/fped.2020.00585] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/07/2020] [Indexed: 12/15/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a novel clinicoradiological syndrome characterized by convulsions, headache, altered mentality, and impaired vision, which are usually accompanied by hypertension. As its nomination, PRES is usually diagnosed according to the presence of typical neuroimage showing vasogenic edema predominately involving the posterior brain area. With the widespread utilization of magnetic resonance imaging (MRI), PRES is becoming more perceptible in different medical fields. Compared to adult cases, childhood PRES seems to have a broader clinical and neuroradiological spectrum. PRES can be associated with various underlying comorbidities, medication use, and therapeutic modalities in children with diverse neurological manifestations. Moreover, pediatric patients with PRES have a more significant propensity for atypical MRI findings beyond the typically posterior cerebral areas. The knowledge of typical and atypical presentations in children is essential to avoid misdiagnosing or missing PRES, which is a potentially treatable entity. Early supportive care is the mainstay of treatment, with particular attention to the treatment of hypertension with rigorous attention to all body systems. Prompt identification and symptom-directed management are imperative to achieve a reversible prognosis in childhood PRES. Future studies specially designed for the child population are required to determine potential outcome predictors, and further, to develop novel strategies of neuroprotection in childhood PRES.
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Affiliation(s)
- Tai-Heng Chen
- Division of Pediatric Emergency, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Section of Neurobiology, Department of Biological Sciences, University of Southern California, Los Angeles, CA, United States.,Ph.D. Program in Translational Medicine, Graduate Institute of Clinical Medicine, Kaohsiung Medical University and Academia Sinica, Taipei, Taiwan
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16
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Chen TH. Childhood Posterior Reversible Encephalopathy Syndrome: Clinicoradiological Characteristics, Managements, and Outcome. Front Pediatr 2020. [PMID: 33042923 DOI: 10.3389/fped.2020.0058534(8):494-500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a novel clinicoradiological syndrome characterized by convulsions, headache, altered mentality, and impaired vision, which are usually accompanied by hypertension. As its nomination, PRES is usually diagnosed according to the presence of typical neuroimage showing vasogenic edema predominately involving the posterior brain area. With the widespread utilization of magnetic resonance imaging (MRI), PRES is becoming more perceptible in different medical fields. Compared to adult cases, childhood PRES seems to have a broader clinical and neuroradiological spectrum. PRES can be associated with various underlying comorbidities, medication use, and therapeutic modalities in children with diverse neurological manifestations. Moreover, pediatric patients with PRES have a more significant propensity for atypical MRI findings beyond the typically posterior cerebral areas. The knowledge of typical and atypical presentations in children is essential to avoid misdiagnosing or missing PRES, which is a potentially treatable entity. Early supportive care is the mainstay of treatment, with particular attention to the treatment of hypertension with rigorous attention to all body systems. Prompt identification and symptom-directed management are imperative to achieve a reversible prognosis in childhood PRES. Future studies specially designed for the child population are required to determine potential outcome predictors, and further, to develop novel strategies of neuroprotection in childhood PRES.
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Affiliation(s)
- Tai-Heng Chen
- Division of Pediatric Emergency, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Section of Neurobiology, Department of Biological Sciences, University of Southern California, Los Angeles, CA, United States.,Ph.D. Program in Translational Medicine, Graduate Institute of Clinical Medicine, Kaohsiung Medical University and Academia Sinica, Taipei, Taiwan
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17
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Shaban A, Leira EC. Neurological Complications in Patients with Systemic Lupus Erythematosus. Curr Neurol Neurosci Rep 2019; 19:97. [PMID: 31773306 DOI: 10.1007/s11910-019-1012-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Systemic lupus erythematosus (SLE) is commonly associated with neurological manifestations. Rapid recognition and treatment of these complications may improve outcomes. In this article, we review the neurological conditions associated with SLE, their diagnosis and management strategies. RECENT FINDINGS Recent meta-analysis showed that patients with neuropsychiatric manifestations of SLE were more likely to have positive antiphospholipid, antiribosomal P, and antineuronal antibodies. Another meta-analysis showed an association between SLE and antiphospholipid antibodies with cognitive impairment. Two large retrospective studies have shown that the peripheral nervous system is commonly involved in SLE frequently alongside the central nervous system. Neurological manifestations occur in most of SLE patients. Antiphospholipid antibodies are common in patients with SLE and increase the odds of neurological complications. Management typically involved a combination of treatments directed toward the neurological complication and therapies directed toward SLE itself. The efficacy of these treatment protocols, however, has not been rigorously studied and deserves further investigation.
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Affiliation(s)
- Amir Shaban
- Department of Neurology, Carver College of Medicine, University of Iowa, 200 Hawkins Dr., Iowa City, IA, 52242, USA.
| | - Enrique C Leira
- Department of Neurology, Carver College of Medicine, University of Iowa, 200 Hawkins Dr., Iowa City, IA, 52242, USA.,Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
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18
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Cui HW, Lei RY, Zhang SG, Han LS, Zhang BA. Clinical features, outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a case-control study. Lupus 2019; 28:961-969. [PMID: 31208267 DOI: 10.1177/0961203319856416] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this paper is to investigate the clinical features, outcomes, and risk factors for posterior reversible encephalopathy syndrome (PRES) in systemic lupus erythematosus (SLE). METHODS From 2011 to October 2017, SLE patients with PRES were identified from the First Affiliated Hospital of Zhengzhou University, China. Patients presenting with neuropsychiatric lupus hospitalized in the same period were included as controls. Additionally, survival status was acquired via telephone follow-up in March 2018. RESULTS Thirty episodes of PRES were identified in 29 SLE patients from a total of 7059 SLE patients (prevalence 0.43%). Patients with PRES had a younger age at onset than controls, with seizures more commonly the initial clinical manifestation (80.00% vs 42.37%, p = 0.001). Multiple logistic regression yet again confirmed several known risk factors, including younger age (odds ratio (OR) 1.15 (95% confidence interval (CI) 1.13-1.16)), nephritis (OR 20.74 (18.10-23.75)), history of hypertension (OR 1.17 (1.05-1.31)), SLE Disease Activity Index without neurologic symptoms (SLEDAI-N) score >12 (OR 1.14 (1.11-1.18)) and eclampsia (OR 9.38 (7.84-11.23)). Furthermore, we identified two novel independent risk factors for PRES in SLE: white blood cells >9 × 109/l (OR 2.33 (2.05-2.64)) and heart failure (OR 2.10 (1.18-2.42)). At follow-up, SLE patients with PRES had higher mortality than controls (30.77% vs 8.33%, respectively, p = 0.012). CONCLUSIONS PRES may be a reversible neurological deficit in patients with SLE other than neuropsychiatric lupus. Our results indicate two new risk factors for PRES and that PRES is associated with a higher mortality rate.
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Affiliation(s)
- H-W Cui
- 1 Department of General ICU, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - R-Y Lei
- 2 Department of Emergency ICU, the First Affiliated Hospital of Zhengzhou University, Henan, Zhengzhou, China
| | - S-G Zhang
- 1 Department of General ICU, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - L-S Han
- 3 Department of Rheumatology, the First Affiliated Hospital of Zhengzhou University, Henan, Zhengzhou, China
| | - B-A Zhang
- 4 Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Henan, Zhengzhou, China
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Liu C, Cao J, Su Z, Xu S. Isolated brainstem involvement in posterior reversible encephalopathy syndrome: a case report and review of the literature. Int J Neurosci 2019; 129:808-813. [PMID: 30590967 DOI: 10.1080/00207454.2018.1561452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological syndrome, reversible vasogenic edema predominantly within parieto-occipital regions. However, isolated brainstem involvement in PRES has been rarely reported, little is known about its clinical manifestations, radiological features and outcomes. We reported a case with PRES with only brainstem involvement and performed a systematic review of published cases. Twenty-four cases, together with our case, were included in the analysis. Mean age was 43 years and 63% were males. Hypertension (50%), nephropathy (25%) and chemotherapy (21%) were the major risk factors. All patients except two had acute hypertension and 50% of patients had renal dysfunction at onset. The most common symptoms were altered consciousness (46%) and headache (46%), Seizure was only presented in 21% of patients. All patients except two were treated with antihypertension. Most patients recovered to their neurological baseline. Clinicians should recognize this unique variant finding in PRES. which always affects males with severe hypertension, especially combined with renal dysfunction. Antihypertensive treatment is the most widely used therapy. Outcome is usually well.
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Affiliation(s)
- Chenchen Liu
- a Department of Neurology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Jie Cao
- a Department of Neurology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Zhuyi Su
- a Department of Neurology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Shabei Xu
- a Department of Neurology, Tongji Hospital, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
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20
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de Amorim JC, Frittoli RB, Pereira D, Postal M, Dertkigil SSJ, Reis F, Costallat LTL, Appenzeller S. Epidemiology, characterization, and diagnosis of neuropsychiatric events in systemic lupus erythematosus. Expert Rev Clin Immunol 2019; 15:407-416. [DOI: 10.1080/1744666x.2019.1564040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jaqueline Cristina de Amorim
- Graduate Program of Child and Adolescent Health, School of Medical Science, University of Campinas, Campinas, Brazil
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Renan Bazuco Frittoli
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
- Graduate Program of Physiopathology, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Danilo Pereira
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
- Graduate Program of Physiopathology, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Mariana Postal
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
| | | | - Fabiano Reis
- Departament of Radiology, School of Medical Science, University of Campinas, Campinas, Brazil
| | - Lilian TL Costallat
- Rheumatology Unit, Department of Medicine-School of Medical Science, University of Campinas, Campinas, Brazil
| | - Simone Appenzeller
- Laboratory of Autoimmune Diseases, School of Medical Science, University of Campinas, Campinas, Brazil
- Rheumatology Unit, Department of Medicine-School of Medical Science, University of Campinas, Campinas, Brazil
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21
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Mustafa KN, Qasem U, Al-Ryalat NT, Bsisu IK. Rituximab-associated posterior reversible encephalopathy syndrome. Int J Rheum Dis 2018; 22:160-165. [PMID: 30398015 DOI: 10.1111/1756-185x.13427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 04/26/2018] [Accepted: 09/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Khader N Mustafa
- Division of Rheumatology, Department of Internal Medicine, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Ula Qasem
- Division of Rheumatology, Department of Internal Medicine, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Nosaiba T Al-Ryalat
- Department of Radiology, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Isam K Bsisu
- School of Medicine, Jordan University Hospital, University of Jordan, Amman, Jordan
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22
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Shah RR. Anti-Angiogenic Tyrosine Kinase Inhibitors and Reversible Posterior Leukoencephalopathy Syndrome: Could Hypomagnesaemia Be the Trigger? Drug Saf 2017; 40:373-386. [PMID: 28181126 DOI: 10.1007/s40264-017-0508-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS), also known frequently as posterior reversible encephalopathy syndrome (PRES), is a characteristic acute neuro-radiology syndrome with clinical presentation that typically includes acute hypertension, seizures and other neurological symptoms and signs. Many patients with RPLS have (a history of) pre-existing hypertension and in receipt of diuretics. It is being diagnosed more frequently and in association with an increasing number of morbidities and medications. Drugs most frequently implicated are immunosuppressant drugs and anticancer agents, including a number of anti-angiogenic tyrosine kinase inhibitors (TKIs). Hypomagnesaemia is a frequent finding at presentation in RPLS patients, which is known to lead to or aggravate hypertension. Pre-eclampsia, a variant of RPLS, responds effectively to intravenous magnesium. Cyclosporin, tacrolimus and some TKIs that induce RPLS are also known to give rise to both hypertension and hypomagnesaemia. This raises an interesting hypothesis that hypomagnesaemia may play a contributory role in triggering RPLS in some patients by acutely raising the blood pressure further. Additional systematic studies are required to test this hypothesis. If the hypothesis is confirmed, hypomagnesaemia offers an effective target for risk mitigation and prevention of RPLS in patients identified at risk.
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Affiliation(s)
- Rashmi R Shah
- Pharmaceutical Consultant, 8 Birchdale, Gerrards Cross, Buckinghamshire, UK.
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23
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Damrongpipatkul U, Oranratanachai K, Kasitanon N, Wuttiplakorn S, Louthrenoo W. Clinical features, outcome, and associated factors for posterior reversible encephalopathy in Thai patients with systemic lupus erythematosus: a case-control study. Clin Rheumatol 2017; 37:691-702. [DOI: 10.1007/s10067-017-3892-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 10/22/2017] [Accepted: 10/24/2017] [Indexed: 11/24/2022]
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Zekić T, Benić MS, Antulov R, Antončić I, Novak S. The multifactorial origin of posterior reversible encephalopathy syndrome in cyclophosphamide-treated lupus patients. Rheumatol Int 2017; 37:2105-2114. [PMID: 29043491 DOI: 10.1007/s00296-017-3843-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/03/2017] [Indexed: 01/13/2023]
Abstract
The cyclophosphamide as a predisposing factor for Posterior Reversible Encephalopathy Syndrome (PRES) and therapeutic option for systemic lupus erythematosus (SLE) is still confusing. The first and only case of PRES, probably induced by cyclophosphamide, in Croatia followed by the findings of 36 SLE patients diagnosed with PRES after treatment with cyclophosphamide worldwide are described. An 18-year-old Caucasian female patient with a 1-year history of SLE was admitted to the hospital due to lupus nephritis and acute arthritis. After the second dose of cyclophosphamide was administered, according to the Euro-lupus protocol, the patient presented with a grand mal status epilepticus. The differential diagnosis of neurolupus, cerebrovascular insult, and infection were excluded. The MRI findings showed brain changes in corresponding to PRES. The treatment consisted of antihypertensives, antiepileptics, antiedema therapy, mechanical ventilation, and avoiding further cyclophosphamide use. A Naranjo Adverse Drug Reaction Probability Scale total score of five and a probable reaction related to drug therapy (cyclophosphamide, PRES) was confirmed. In this systematic review, along with cyclophosphamide use, the main predisposing factors involved in PRES occurrence in SLE patients were active SLE and renal involvement. Due to the high number of simultaneously involved predisposing factors (max. six) and their overlapping effect, it is still not possible to clearly establish the role of every factor on PRES onset. The use of cyclophosphamide, as a contributing factor for PRES onset, should be carefully assessed, based on clinicians' experience and knowledge, in the setting of active SLE.
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Affiliation(s)
- Tatjana Zekić
- Department of Rheumatology and Clinical Immunology, Clinical Hospital Centre Rijeka, Krešimirova 42, 51000, Rijeka, Croatia.
| | - Mirjana Stanić Benić
- Department of Clinical Pharmacology, Clinical Hospital Centre Rijeka, Krešimirova 42, 51000, Rijeka, Croatia.
| | - Ronald Antulov
- Department of Radiology, Sydvestjyisk Sygehus, Esbjerg, Denmark
| | - Igor Antončić
- Department of Neurology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
- University of Rijeka Medical School, Rijeka, Croatia
| | - Srđan Novak
- Department of Rheumatology and Clinical Immunology, Clinical Hospital Centre Rijeka, Krešimirova 42, 51000, Rijeka, Croatia
- University of Rijeka Medical School, Rijeka, Croatia
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25
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Parikh NS, Schweitzer AD, Young RJ, Giambrone AE, Lyo J, Karimi S, Knobel A, Gupta A, Navi BB. Corticosteroid therapy and severity of vasogenic edema in posterior reversible encephalopathy syndrome. J Neurol Sci 2017; 380:11-15. [PMID: 28870548 DOI: 10.1016/j.jns.2017.06.044] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/28/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a variable cerebrovascular syndrome associated with hypertension and autoregulatory failure. Steroids have been reported to both precipitate and treat PRES. We sought to determine the prevalence of steroid therapy at the time of PRES and to assess the relationship between steroid therapy and extent of vasogenic edema. METHODS We performed a retrospective review of radiology reports between 2008 and 2014 from two academic medical centers to identify cases of PRES. Clinical and radiographic data were collected. Descriptive statistics were used to determine the prevalence of corticosteroid therapy at the time of PRES onset and the latency from steroid initiation to PRES onset. The association between steroid therapy and extent of vasogenic edema was assessed in multiple regression models. RESULTS We identified 99 cases of PRES in 96 patients. The median age was 55years (IQR 30-65) and 74% were women. Steroid therapy at time of PRES onset was identified in 44 of 99 cases. Excluding patients on chronic therapy, the median duration of steroid exposure before PRES onset was 6 (IQR, 3-10) days. Steroid therapy was not associated with extent of vasogenic edema in unadjusted or linear and logistic regression models adjusted for age, sex, and maximum systolic blood pressure on day of onset. CONCLUSION Corticosteroid therapy, often of brief duration, frequently preceded the onset of PRES and was not associated with severity of vasogenic edema.
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Affiliation(s)
- Neal S Parikh
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA.
| | | | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ashley E Giambrone
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
| | - John Lyo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sasan Karimi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anna Knobel
- Department of Radiology, Lenox Hill Hospital, New York, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA; Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA; Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
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26
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Schweitzer AD, Parikh NS, Askin G, Nemade A, Lyo J, Karimi S, Knobel A, Navi BB, Young RJ, Gupta A. Imaging characteristics associated with clinical outcomes in posterior reversible encephalopathy syndrome. Neuroradiology 2017; 59:379-386. [PMID: 28289809 DOI: 10.1007/s00234-017-1815-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 02/22/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Posterior reversible encephalopathy syndrome (PRES) is a disorder of cerebrovascular autoregulation that can result in brain edema, hemorrhage, and infarction. We sought to investigate whether certain imaging characteristics in PRES are associated with clinically significant patient outcomes. METHODS We retrospectively reviewed all cases of PRES occurring between 2008 and 2014 at two major academic medical centers. Demographic, clinical, and radiographic data were collected. We analyzed imaging studies for vasogenic edema, hemorrhage, and diffusion restriction. We performed univariate analysis and stepwise logistic regression to assess the association between our radiologic findings of interest and clinical outcomes as defined by hospital discharge disposition and modified Rankin scale (mRS) at time of discharge. RESULTS We identified 99 cases of PRES in 96 patients. The median age was 55 years (IQR 30-65) and 74% were women. In 99 cases, 60% of patients had active cancer, 19% had history of bone marrow or organ transplantation, 14% had autoimmune disease, and 8% were peripartum. Imaging at clinical presentation showed extensive vasogenic edema in 39%, hemorrhage in 36%, hemorrhage with mass effect in 7%, and restricted diffusion in 16%. In our final logistic regression models, the presence of extensive vasogenic edema, hemorrhage with mass effect, or diffusion restriction was associated with worse clinical outcome as defined by both discharge disposition (OR = 4.3; 95% CI: 1.4-36.3; p = 0.047) and mRS (OR = 3.6; 95% CI: 1.2-10.7; p = 0.019). CONCLUSIONS Extensive vasogenic edema, hemorrhage, and restricted diffusion on initial imaging in PRES are associated with worse clinical outcomes.
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Affiliation(s)
- Andrew D Schweitzer
- Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, Box 141, Office: Starr 8A-29, New York, NY, 10065, USA.
| | - Neal S Parikh
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Gulce Askin
- Department of Healthcare Policy & Research, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | - Ajay Nemade
- Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, Box 141, Office: Starr 8A-29, New York, NY, 10065, USA
| | - John Lyo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sasan Karimi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anna Knobel
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Robert J Young
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, 525 E. 68th Street, Box 141, Office: Starr 8A-29, New York, NY, 10065, USA.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
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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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28
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[Reversible posterior leukoencephalopathy syndrome in a patient presenting granulomatosis with polyangiitis]. Ann Dermatol Venereol 2016; 144:113-120. [PMID: 27502754 DOI: 10.1016/j.annder.2016.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 03/19/2016] [Accepted: 06/21/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Reversible posterior leukoencephalopathy syndrome (RPLS) is characterised by clinical neurological features of sudden onset and brain MRI findings such as T2/Flair white matter hyperintensities. RPLS can occur in autoimmune diseases, and rarely in systemic vasculitis. We report a case of RPLS in a woman presenting granulomatosis with polyangiitis (Wegener's granulomatosis). PATIENTS AND METHODS A 22-year-old female patient was treated with methylprednisolone pulses for granulomatosis with polyangiitis and neurological impairment. A few hours after the second pulse, the patient had seizures, blindness and confusion associated with high blood pressure and acute renal failure. MRI revealed a high-intensity area on T2-Flair weighted images of the occipital-temporal lobes. The patient was treated with antiepileptic and antihypertensive medications, oral steroids and cyclophosphamide; the clinical and radiological findings proved reversible over the ensuing days. DISCUSSION The occurrence of RPLS in systemic vasculitis is rare. Six cases of RPLS associated with granulomatosis and polyangiitis have been reported. It appears important to screen for high blood pressure in patients recently treated with corticosteroids for vasculitis as this condition may represent a precipitating factor for RPLS.
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29
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Solh Z, Taccone MS, Marin S, Athale U, Breakey VR. Neurological PRESentations in Sickle Cell Patients Are Not Always Stroke: A Review of Posterior Reversible Encephalopathy Syndrome in Sickle Cell Disease. Pediatr Blood Cancer 2016; 63:983-9. [PMID: 26871763 DOI: 10.1002/pbc.25932] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/24/2015] [Accepted: 01/12/2016] [Indexed: 01/05/2023]
Abstract
Acute neurological changes in sickle cell disease (SCD) patients often raise the suspicion for stroke. Posterior reversible encephalopathy syndrome (PRES) can mimic stroke in its clinical presentation. We aimed to (i) review the PRES literature in SCD patients including clinical presentation, risk factors, pathophysiology, and management and (ii) elucidate the distinction between PRES and stroke in SCD. The exact pathophysiology of PRES in SCD remains elusive but is likely multifactorial and related to sickling, ischemia, and chronic anemia predisposing to vasogenic edema. PRES and stroke in SCD are distinguishable conditions. Our review may help elucidate a clinical approach to this distinction.
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Affiliation(s)
- Ziad Solh
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Michael S Taccone
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Samantha Marin
- Division of Pediatric Neurology, Department of Pediatrics, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Uma Athale
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Vicky R Breakey
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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Merayo-Chalico J, Apodaca E, Barrera-Vargas A, Alcocer-Varela J, Colunga-Pedraza I, González-Patiño A, Arauz A, Abud-Mendoza C, Martínez-Martínez M, Gómez-Martín D. Clinical outcomes and risk factors for posterior reversible encephalopathy syndrome in systemic lupus erythematosus: a multicentric case-control study. J Neurol Neurosurg Psychiatry 2016; 87:287-94. [PMID: 25804426 DOI: 10.1136/jnnp-2014-310145] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 03/02/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a well-known but rare complication in patients (<1%) with systemic lupus erythematosus (SLE). However, current epidemiological data are quite scant. The aim of the present study was to describe potentially unrecognised risk factors. PATIENTS AND METHODS We performed a multicentre, retrospective case-control study in Mexico between 1999 and 2014. We included a total of 168 patients who accounted for 77 episodes of PRES, as follows: SLE/PRES, 43 patients with 48 episodes; SLE without PRES, 96 patients; and PRES without SLE, 29 patients. SLE diagnosis was considered when patients fulfilled ≥4 American College of Rheumatology criteria. PRES was defined by reversible neurological manifestations and MRI changes. RESULTS Patients with SLE/PRES were younger, presented with seizures as the most common manifestation (81%) and 18% had the typical occipital MRI finding. Hypertension (OR=16.3, 95% CI 4.03 to 65.8), renal dysfunction (OR=6.65, 95% CI 1.24 to 35.6), lymphopenia (OR=5.76, 95% CI 1.36 to 24.4), Systemic Lupus Erythematosus Activity Index ≥ 6 points (OR=1.11, 95% CI 1.01 to 1.22) and younger age (OR=0.86, 95% CI 0.81 to 0.91, p<0.001) were independent risk factors for development of PRES in SLE. Furthermore, dyslipidemia also characterised the association between PRES and SLE (OR=10.6, 95% CI 1.17 to 96.4). CONCLUSIONS This is the largest reported series of patients with SLE and PRES. We were able to corroborate the known risk factors for of PRES, and found two previously undescribed factors (lymphopenia and dyslipidemia), which suggests that endothelial dysfunction is a key element in PRES pathogenesis in lupus patients.
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Affiliation(s)
- Javier Merayo-Chalico
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elia Apodaca
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ana Barrera-Vargas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jorge Alcocer-Varela
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Iris Colunga-Pedraza
- Department of Rheumatology, Hospital Universitario Dr José E González, Monterrey, Nuevo León, Mexico
| | - Alejandra González-Patiño
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Carlos Abud-Mendoza
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Marco Martínez-Martínez
- Regional Unit of Rheumatology and Osteoporosis, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - Diana Gómez-Martín
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Budhoo A, Mody GM. The spectrum of posterior reversible encephalopathy in systemic lupus erythematosus. Clin Rheumatol 2015; 34:2127-34. [PMID: 26298534 DOI: 10.1007/s10067-015-3055-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/12/2015] [Accepted: 08/12/2015] [Indexed: 11/30/2022]
Abstract
Our aim was to compare our South African cohort of systemic lupus erythematosus (SLE) and posterior reversible encephalopathy syndrome (PRES) with other published series. We reviewed the records of 10 patients with SLE and PRES seen over a 10-year period and their demographic data, clinical manifestations, laboratory tests, imaging findings, and outcome were recorded. We identified 10 females who included six Indians, three mixed ethnicity, and one African Black. Three patients had PRES at the onset of SLE. The most common manifestations at presentation were seizures (100 %), hypertension (80 %), and altered mental state (50 %). On neuroimaging, nine patients had bilateral involvement, and the occipital (90 %), parietal (90 %), and frontal lobes (50 %) were most commonly involved. The risk factors for PRES were disease activity (90 %), renal disease (80 %) and hypertension (80 %). Ninety percent of the patients were on immunosuppressive therapy. Immunosuppressive therapy was increased in six patients (60 %), continued in two and reduced in two patients after the diagnosis of PRES. Seven patients recovered completely and three patients died from co-morbidities. A review of the larger case series of SLE and PRES showed that the presentation and neuroimaging findings were similar; most patients had active disease at the time of PRES and the majority of patients required intensification of immunosuppressive therapy. We have shown that the majority of patients with SLE have active disease at the time of PRES, and they require an increase in their immunosuppressive therapy.
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Affiliation(s)
- Amritha Budhoo
- Department of Rheumatology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Girish M Mody
- Department of Rheumatology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
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Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. Lancet Neurol 2015; 14:914-925. [PMID: 26184985 DOI: 10.1016/s1474-4422(15)00111-8] [Citation(s) in RCA: 668] [Impact Index Per Article: 74.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 04/08/2015] [Accepted: 05/27/2015] [Indexed: 12/12/2022]
Abstract
Almost two decades have elapsed since posterior reversible encephalopathy syndrome (PRES) was described in an influential case series. This usually reversible clinical syndrome is becoming increasingly recognised, in large part because of improved and more readily available brain imaging. Although the pathophysiological changes underlying PRES are not fully understood, endothelial dysfunction is a key factor. A diagnosis of PRES should be considered in the setting of acute neurological symptoms in patients with renal failure, blood pressure fluctuations, use of cytotoxic drugs, autoimmune disorders, or eclampsia. Characteristic radiographic findings include bilateral regions of subcortical vasogenic oedema that resolve within days or weeks. The presence of haemorrhage, restricted diffusion, contrast enhancement, and vasoconstriction are all compatible with a diagnosis. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. The range of symptoms that can comprise the syndrome might be broader than usually thought. In its mild form, this disorder might cause only one clinical symptom (headache or seizure) and radiographically might show few areas of vasogenic oedema or even normal brain imaging in some rare cases. In severe forms, PRES might cause substantial morbidity and even mortality, most often as a result of acute haemorrhage or massive posterior fossa oedema causing obstructive hydrocephalus or brainstem compression.
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Kim D, Cho SK, Sung YK. The Present and Future of Clinical Research for Korean Lupus Patients. JOURNAL OF RHEUMATIC DISEASES 2014. [DOI: 10.4078/jrd.2014.21.2.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Dam Kim
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Soo-Kyung Cho
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Yoon-Kyoung Sung
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
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