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Funken D, Götz F, Bültmann E, Hennies I, Gburek-Augustat J, Hempel J, Dressler F, Baumann U, Klemann C. Focal Seizures and Posterior Reversible Encephalopathy Syndrome as Presenting Signs of IgA Vasculitis/Henoch-Schoenlein Purpura-An Educative Case and Systematic Review of the Literature. Front Neurol 2021; 12:759386. [PMID: 34867743 PMCID: PMC8634645 DOI: 10.3389/fneur.2021.759386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background: IgA vasculitis/Henoch-Schoenlein purpura (IgAV/HSP) is a systemic small vessel vasculitis of unknown pathogenesis predominantly affecting children. While skin, GI tract, joints, and kidneys are frequently affected and considered, central nervous system (CNS) involvement of this disease is underestimated. Methods: We provide a case report and systematically review the literature on IgAV, collecting data on the spectrum of neurological manifestations. Results: We report on a 7-year-old girl with IgAV who presented with diplopia and afebrile focal seizures, which preceded the onset of purpura. Cranial magnetic resonance imaging was consistent with posterior reversible encephalopathy syndrome (PRES), showing typical focal bilateral parietal swelling and cortical and subcortical high signal intensities on T2-fluid attenuated inversion recovery (FLAIR) images predominantly without diffusion restriction. Cerebrospinal fluid analysis and blood tests excluded systemic inflammation or vasculitis. Interestingly, hypertension was not a hallmark of the developing disease in the initial phase of PRES manifestation. Renal disease and other secondary causes for PRES were also excluded. Supportive- and steroid treatment resulted in restitution ad integrum. Reviewing the literature, we identified 28 other cases of IgAV with CNS involvement. Severe CNS involvement includes seizures, cerebral edema, or hemorrhage, as well as PRES. Thirteen patients fulfilled all diagnostic criteria of PRES. The mean age was 11.2 years (median 8.0, range 5-42 years), with no reported bias toward gender or ethnic background. Treatment regimens varied from watchful waiting to oral and intravenously steroids up to plasmapheresis. Three cases showed permanent CNS impairment. Conclusion: Collectively, our data demonstrate that (I) severe CNS involvement such as PRES is an underappreciated feature of IgAV, (II) CNS symptoms may precede other features of IgAV, (III) PRES can occur in IgAV, and differentiation from CNS vasculitis is challenging, (IV) pathogenesis of PRES in the context of IgAV remains elusive, which hampers treatment decisions. We, therefore, conclude that clinical awareness and the collection of structured data are necessary to elucidate the pathophysiological connection of IgAV and PRES.
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Affiliation(s)
- Dominik Funken
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hanover, Germany
| | - Friedrich Götz
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hanover, Germany
| | - Eva Bültmann
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hanover, Germany
| | - Imke Hennies
- Department of Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hanover, Germany
| | - Janina Gburek-Augustat
- Division of Neuropediatrics, Hospital for Children and Adolescents, University Hospital Leipzig, Leipzig, Germany
| | - Julya Hempel
- Department of Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hanover, Germany
| | - Frank Dressler
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hanover, Germany
| | - Ulrich Baumann
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hanover, Germany
| | - Christian Klemann
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hanover, Germany
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Fikse DJ, Grenz PM, Wheatley SM, Fugok KL. Posterior reversible encephalopathy syndrome associated with Henoch Schonlein Purpura in a pediatric patient. Am J Emerg Med 2020; 43:291.e5-291.e7. [PMID: 33097321 DOI: 10.1016/j.ajem.2020.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/02/2020] [Indexed: 10/23/2022] Open
Abstract
Henoch Schonlein Purpura is a rare hypersensitivity vasculitis that is commonly associated with pediatric patients. It typically presents with purpuric rash to the lower extremities, abdominal pain and microscopic hematuria; however, it may also be associated with intussusception, glomerulonephritis and hypertension. Posterior Reversible Encephalopathy Syndrome is a poorly understood, rare condition associated with cerebral edema and segmental vasoconstriction. Typically characterized by headaches, seizures, and visual changes, which is presumed to be associated with rapid increases in blood pressure. We present the case of a 6-year-old female who developed Posterior Reversible Encephalopathy Syndrome as a complication from Henoch Schonlein Purpura.
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Affiliation(s)
- Derek J Fikse
- Division of Pediatric Emergency Medicine, Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Lehigh Valley Reilly Children's Hospital of the Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA 18103, USA
| | - Phillip M Grenz
- Division of Pediatric Emergency Medicine, Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Lehigh Valley Reilly Children's Hospital of the Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA 18103, USA
| | - Scott M Wheatley
- Lehigh Valley Health Network, Department of Pediatrics, Lehigh Valley Reilly Children's Hospital of the Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Lehigh Valley Campus, Cedar Crest Blvd & I-78, Allentown, PA 18103, USA
| | - Kimberly L Fugok
- Division of Pediatric Emergency Medicine, Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Lehigh Valley Reilly Children's Hospital of the Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA 18103, USA.
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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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Successful Management of a Rare Cause of Hemolytic Uremic Syndrome With Eculizumab in a Child. J Pediatr Hematol Oncol 2018; 40:401-404. [PMID: 29578925 DOI: 10.1097/mph.0000000000001121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, acute renal failure, and thrombocytopenia. It very rarely coexists with acute lymphoblastic leukemia (ALL) emerging before, simultaneously, or after the diagnosis has been made, and management of the patient may be difficult. CASE We present the case of a 7-year-old boy who was diagnosed with HUS and initially managed by hemodialysis (HD). Thereafter, HUS progressed, and neurological findings developed. The patient was treated with eculizumab, agressive blood pressure control, and antiepileptic drugs. At the fifth month of follow-up, the patient was diagnosed with acute B-cell lymphoblastic leukemia with fever, bone pain, hepatosplenomegaly, and pancytopenia. After initiation of ALL treatment, he had no episodes of HUS, despite cessation of eculizumab. CONCLUSION In conclusion, eculizumab may be a treatment of choice to prevent further systemic damage in recurrent HUS episodes of patients with borderline changes in the bone marrow until ALL is constantly diagnosed.
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Lava SAG, Peeters GGAM, Bianchetti MG, Goeggel Simonetti B, Simonetti GD, Milani GP. Posterior reversible encephalopathy syndrome in Henoch-Schönlein purpura. Rheumatol Int 2016; 37:461-463. [PMID: 27770226 DOI: 10.1007/s00296-016-3577-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/04/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Sebastiano A G Lava
- Department of Pediatrics, University Children's Hospital of Bern, Inselspital, Bern, Switzerland.,Pediatric Department of Southern Switzerland, Bellinzona, Switzerland.,Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, Paris, France
| | - Gabriëlla G A M Peeters
- Pediatric Emergency Department, Foundation IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Via della Commenda 9, 20133, Milan, Italy
| | | | - Barbara Goeggel Simonetti
- Pediatric Department of Southern Switzerland, Bellinzona, Switzerland.,Department of Neurology, University Hospital Inselspital Bern, Bern, Switzerland
| | - Giacomo D Simonetti
- Department of Pediatrics, University Children's Hospital of Bern, Inselspital, Bern, Switzerland.,Pediatric Department of Southern Switzerland, Bellinzona, Switzerland
| | - Gregorio P Milani
- Pediatric Emergency Department, Foundation IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Via della Commenda 9, 20133, Milan, Italy.
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