Posterior Reversible Encephalopathy Syndrome in a Pediatric COVID-19 Patient.

Novel coronavirus disease 2019 is a viral infectious disease which commonly involve the lungs with primarily radiologic manifestations of atypical or organizing pneumonia. It can cause multisystemic involvement including central nervous system symptoms. One of these neurologic manifestations is posterior reversible encephalopathy syndrome (PRES). It is suggested that the increased levels of cytokines and inflammatory mediators in the course of the disease are responsible for cerebrovascular endothelial dysfunction and disruption of the blood-brain barrier. To the best of our knowledge, no pediatric PRES has been reported related to coronavirus disease 2019. Here, we present a pediatric PRES case associated with severe acute respiratory syndrome coronavirus 2 infection.

Encephalopathy with progression to posterior reversible encephalopathy pattern in a patient with COVID-19: clinical, imaging findings and follow-up.

Neurological conditions are being more recognised in patients with COVID-19, with encephalopathy being the most prevalent problem. Posterior reversible encephalopathy is suspected to occur due to elevated blood pressure and overproduction of inflammatory markers, both of which have been reported in the setting of COVID-19 infection. Encephalopathy was the main presentation in this case, without respiratory dysfunction initially, and with imaging findings indicative of posterior reversible encephalopathy syndrome as an aetiology. Follow-up imaging showed resolution of the abnormal results with mental status returning to baseline upon discharge.

Posterior Reversible Encephalopathy Syndrome in Patients with Coronavirus Disease 2019: Two Cases and A Review of The Literature.

INTRODUCTION: Encephalopathy is a common complication of coronavirus disease 2019. Although the encephalopathy is idiopathic in many cases, there are several published reports of patients with posterior reversible encephalopathy syndrome in the setting of coronavirus disease 2019. OBJECTIVE: To describe the diverse presentations, risk factors, and outcomes of posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019. METHODS: We assessed patients with coronavirus disease 2019 and a diagnosis of posterior reversible encephalopathy syndrome at our institution from April 1 to June 24, 2020. We performed a literature search to capture all known published cases of posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019. RESULTS: There were 2 cases of posterior reversible encephalopathy syndrome in the setting of coronavirus 2019 at our institution during a 3-month period. One patient was treated with anakinra, an interleukin-1 inhibitor that may disrupt endothelial function. The second patient had an underlying human immunodeficiency virus infection. We found 13 total cases in our literature search, which reported modest blood pressure fluctuations and a range of risk factors for posterior reversible encephalopathy syndrome. One patient was treated with tocilizumab, an interleukin-6 inhibitor that may have effects on endothelial function. All patients had an improvement in their neurological symptoms. Interval imaging, when available, showed radiographic improvement of brain lesions. CONCLUSIONS: Risk factors for posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019 may include underlying infection or immunomodulatory agents with endothelial effects in conjunction with modest blood pressure fluctuations. We found that the neurological prognosis for posterior reversible encephalopathy syndrome in the setting of coronavirus disease 2019 infection is favorable. Recognition of posterior reversible encephalopathy syndrome in this patient population is critical for prognostication and initiation of treatment, which may include cessation of potential offending agents and tight blood pressure control.

COVID-19-Associated PRES-like Encephalopathy with Perivascular Gadolinium Enhancement.

We describe the case of a 63-year-old woman who developed a coronavirus disease 2019-associated acute encephalopathy with perivascular gadolinium enhancement.

Neurological emergencies associated with COVID-19: stroke and beyond.

Novel coronavirus disease (COVID-19) was declared a global pandemic on March 1, 2020. Neurological manifestations are now being reported worldwide, including emergent presentation with acute neurological changes as well as a comorbidity in hospitalized patients. There is limited knowledge on the neurologic manifestations of COVID-19 at present, with a wide array of neurological complications reported, ranging from ischemic stroke to acute demyelination and encephalitis. We report five cases of COVID-19 presenting to the ER with acute neurological symptoms, over the course of 1 month. This includes two cases of ischemic stroke, one with large-vessel occlusion and one with embolic infarcts. The remainders of the cases include acute tumefactive demyelination, isolated cytotoxic edema of the corpus callosum with subarachnoid hemorrhage, and posterior reversible encephalopathy syndrome (PRES).

Reversible Encephalopathy Syndrome (PRES) in a COVID-19 patient.

Recently WHO has declared novel coronavirus disease 2019 (COVID-19) outbreak a pandemic. Acute respiratory syndrome seems to be the most common manifestation of COVID-19. Besides pneumonia, it has been demonstrated that SARS-CoV-2 infection affects multiple organs, including brain tissues, causing different neurological manifestations, especially acute cerebrovascular disease (ischemic and hemorrhagic stroke), impaired consciousness and skeletal muscle injury. To our knowledge, among neurological disorders associated with SARS-CoV2 infection, no Posterior Reversible Encephalopathy Syndrome (PRES) has been described yet. Herein, we report a case of a 64-year old woman with COVID19 infection who developed a PRES, and we suggest that it could be explained by the disruption of the blood brain barrier induced by the cerebrovascular endothelial dysfunction caused by SARS-CoV-2.

Posterior reversible encephalopathy syndrome concurrent with human herpesvirus-6B encephalitis after allogeneic hematopoietic stem cell transplantation.

Posterior reversible encephalopathy syndrome (PRES) and human herpesvirus (HHV)-6 encephalitis are both serious neurological complications post hematopoietic stem cell transplantation. Although infection is one of the important causes of PRES, only few cases have reported the relation between PRES and viral infection. Herein, we report the first adult case of PRES concurrent with HHV-6 encephalitis after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia. This case suggests that HHV-6 reactivation is associated with the pathogenesis of PRES. Also, PRES and HHV-6 encephalitis cause similar symptoms, and switching the immunosuppressant from calcineurin inhibitor to prednisolone for treating PRES may worsen HHV-6 encephalitis. Therefore, we should pay attention to the complication of HHV-6 encephalitis even after PRES is diagnosed.

Posterior reversible encephalopathy syndrome in an HIV-infected patient on antiretroviral treatment: what is the risk factor?

Posterior reversible encephalopathy syndrome (PRES) is a rare but well-described syndrome associated with a high morbidity and a substantial mortality. We present an illustrative case of an HIV-infected but virologically suppressed patient who complained of visual impairment accompanied by severe headache and epileptic seizures. The cerebral CT scan and the follow-up cranial MRI confirmed the diagnosis of PRES. Unlike the cases of HIV-infected patients with PRES published so far, our patient suffered neither from advanced immunodeficiency nor from opportunistic infection or from any other evident predisposing factor. This case highlights that the absence of classical risk factors does not exclude the diagnosis of PRES. We discuss the hypothesis that in accordance with the new pathophysiological theory, persistent HIV-associated cerebrovascular reactivity in combination with endothelial dysfunction may represent an undetected risk factor for the development of PRES in virologically and immunologically stable patients.

Dengue encephalopathy: very unusual neuroimaging findings.

Neuroimaging, in many patients with dengue encephalopathy, may reveal periventricular signal changes. We report a 25-year-old man, who presented with altered sensorium. Dengue-IgM test in serum was positive. Cerebrospinal fluid examination was normal. MRI brain revealed presence of bilateral parieto-occipital intraparenchymal bleed with mass effect. Neuroimaging was consistent with posterior reversible encephalopathy syndrome. We report posterior reversible encephalopathy syndrome in a normotensive patient with dengue encephalopathy and systemic metabolic alterations.

Posterior reversible encephalopathy syndrome in disseminated histoplasmosis and advanced HIV infection.

The cause of posterior reversible encephalopathy syndrome (PRES) is often multifactorial. It is uncommon in patients with human immunodeficiency virus (HIV) infection. However, if the cause of PRES is left untreated it can cause significant morbidity and mortality. Thus, we believe it should be included as a differential in immunosuppressed patients presenting with neurological signs. This case report describes such a patient with acquired immunodeficiency syndrome (AIDS) who developed hypocalcaemia secondary to disseminated histoplasmosis.

Progressive multifocal leukoencephalopathy in multiple sclerosis.

AIDS generated a significantly increased interest in the pathogenesis, clinical manifestations, and treatment of progressive multifocal leukoencephalopathy (PML), a disease previously considered to be very rare. Scrutiny increased after a second wave of PML following the introduction of biological agents, in particular, natalizumab and efalizumab. While efalizumab, a lymphocyte function-associated antigen 1 inhibitor marketed for use in psoriasis, has been removed from the market, natalizumab, an α4ß1 and α4ß7 integrin inhibitor, remains widely used in the treatment of multiple sclerosis (MS). Approximately 400 cases of natalizumab-associated PML have been reported from 2005 to August 2013. Additionally, other therapies currently employed or under development for the treatment of MS may also be associated with PML, such as mycophenolate mofetil, rituximab, and alemtuzumab. Therefore, practitioners using these medications need to understand the risks associated with these agents, ways to mitigate the risk, and treatment of PML and the related condition PML immune reconstitution inflammatory syndrome. PML associated with the use of therapeutic agents, especially, natalizumab, does share similarities with HIV-related PML; however, distinct differences exist. Radiographically isolated PML is seen more commonly with natalizumab-associated PML and the disease appears to be heralded more often by cognitive and behavior disturbances. Furthermore, the mortality of natalizumab-associated PML is substantially lower. Risk mitigation strategies have been developed for the natalizumab-associated PML, which has been convincingly demonstrated to be linked to duration of therapy, JC virus seropositivity, and the prior use of immunosuppressive agents.

Posterior reversible encephalopathy syndrome (PRES) in an HIV-1 infected patient with disseminated varicella zoster virus: a case report.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is an uncommon pathology characterized by the acute onset of headache, vomiting, altered consciousness, seizures and focal neurological deficits. It was initially described in the setting of hypertension, uremia and immunosuppression. In the last decade there have been emerging reports of PRES in patients with advanced human immunodeficiency virus (HIV)-infection in the presence of hypertension, dialysis, hypercalcaemia and two opportunistic infections: blastomycosis and tuberculosis (TB). CASE PRESENTATION: Here we present the case of a 54 year old male being treated for disseminated varicella zoster virus (VZV) and vasculopathy in the setting of HIV infection who acutely deteriorated to the point of requiring intubation. His clinicoradiological diagnosis was of PRES and he subsequently improved within 72 h with supportive management. Serial neuroimaging correlated with the clinical findings. The pathogenesis of PRES is poorly understood but is thought to stem from vasogenic oedema either as a result of loss of endothelial integrity and transudate of fluid across the blood-brain barrier, or secondary to vasospasm resulting in tissue oedema in the absence of infarction. How HIV infection impacts on this model is unclear. It is possible the HIV infection causes endothelial dysfunction and disruption of the blood-brain barrier that may be further exacerbated by infections in the central nervous system. CONCLUSION: The phenomenon of PRES in advanced HIV is an important clinical entity for both physicians and critical care doctors to recognize firstly given its potential mortality but also because of its favourable prognosis and reversibility with supportive care and treatment of underlying causes.

Central nervous system complications and neuroradiological findings in children with chronic active Epstein-Barr virus infection.

BACKGROUND: Although many neurological complications have been described in acute Epstein-Barr virus infection, few reports have discussed the central nervous system complications in chronic active Epstein-Barr virus (CAEBV) infection. METHODS: We retrospectively surveyed the medical records of 14 patients with CAEBV infection in our institute. Neuroradiological studies were performed in 10 of these patients. RESULTS: Five had no neurological symptoms, whereas two presented with posterior reversible encephalopathy syndrome, one presented with basal ganglia calcification, and one presented with falx cerebri hemorrhage. Although both of the posterior reversible encephalopathy syndrome cases developed epilepsy several years after recovering from prolonged neurological deterioration, the others had no neurological sequelae. CONCLUSIONS: This study revealed that various central nervous system complications may occur during the clinical course in pediatric CAEBV patients.

Influenza A-induced rhabdomyolysis and acute kidney injury complicated by posterior reversible encephalopathy syndrome.

We report a case of Influenza A-induced rhabdomyolysis causing acute kidney injury in a young adult female who required invasive ventilation and renal replacement therapy. This case was further complicated by posterior reversible encephalopathy syndrome. Although this represents an extremely rare neurological complication of Influenza A infection, an appreciation of the condition and its management is important, given the high numbers of critically ill patients recently affected by H1N1 Influenza A in intensive care units in the UK.

Influenza A encephalopathy, cerebral vasculopathy, and posterior reversible encephalopathy syndrome: combined occurrence in a 3-year-old child.

Encephalopathy is an uncommon complication of childhood influenza infection, typically recognized during influenza epidemics. Imaging hallmarks include characteristic thalamic lesions, thalamic necrosis and hemispheric edema. We describe a child with acute influenza A associated necrotizing encephalopathy with MR angiographic evidence of significant cerebral vasculopathy and a hemispheric edema pattern consistent with PRES. This case reinforces that significant cerebral vasculopathy can accompany influenza infection and that influenza is a likely trigger for PRES.

Reversible posterior leukoencephalopathy syndrome in 2 HIV-infected patients receiving antiretroviral therapy.

We describe 2 human immunodeficiency virus-infected patients who developed hypertension and severe neurological abnormalities while receiving successful antiretroviral therapy. Neuroimaging findings were characteristic of reversible posterior leukoencephalopathy syndrome, a brain-capillary leak syndrome with hypertension and endothelial damage. We discuss the role of antiretroviral therapy-associated metabolic alterations in endothelial damage, hypertension, and reversible posterior leukoencephalopathy syndrome.