Posterior Reversible Encephalopathy Syndrome and Subarachnoid Hemorrhage After Methylprednisolone Pulse Therapy for a patient with Lupus Nephritis

ABSTRACT

Introduction@#Systemic lupus erythematosus (SLE) is a chronic inflammatory systemic disease that can affect any organ including the central nervous system (CNS). Subarachnoid hemorrhage (SAH) is one of its rare CNS manifestations. Posterior reversible encephalopathy syndrome (PRES), with features of headache, seizures, altered mental status, visual loss, and typical imaging findings, has recently been associated with SLE and immunosuppression, including use of high dose steroids. The patient was seen in University of the Philippines-Philippine General Hospital (UP-PGH), a tertiary training hospital in Manila, Philippines@*Case@#A 33-year-old female with lupus had PRES and SAH after methylprednisolone pulse therapy (MPPT) for nephritis. She presented with headache, hypertension and seizure. Initial cranial imaging showed hypodense areas in both parietotemprooccipital regions and small acute infarcts. She was intubated and treated with anti-convulsants for seizure; hydrocortisone and mycophenolate mofetil for SLE. She regained awareness on the seventh hospital day and was extubated. On the eleventh hospital day, she had fever, cough and was noted to be drowsy. She had increasing serum creatinine and decrease in urine output. Repeat cranial CT scan showed subarachnoid hemorrhage at the right sylvian fissure and better delineation of the previously described hypodensities (consistent with PRES). She was treated for hospital acquired pneumonia and underwent hemodialysis. Pneumonia was resolved and patient became conscious with no recurrence of neurologic symptoms. Consecutive outpatient visits showed a conscious and less edematous patient. Hemodialysis was eventually discontinued until she had normal creatinine with adequate urine output. Anti-seizure medications were also discontinued. Cranial CT scan a year later revealed normal brain parenchyma indicating resolution of previously noted hypodensities and subarachnoid hemorrhage.@*Conclusion@#There is a need to recognize PRES and differentiate it from irreversible neurologic conditions. With early identification and prompt intervention, permanent neurologic deficits may be prevented.