A case of posterior reversible encephalopathy syndrome (PRES) in an eskd patient with COVID-19

ABSTRACT

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome first reported in 1996 which describes the presence of a wide range of neurological symptoms, and posterior brain white matter edema on imaging studies which may be reversible. The clinical presentation is characterized by headache, altered consciousness, visual disturbances and seizures;hypertension is frequent, although not invariable. Case Description A 37-year-old male with past medical history of hypertension and end stage kidney disease on hemodialysis who presented with shortness of breath, occipital headache, and bilateral acute vision loss. On admission, he was afebrile with a blood pressure of 274/147 mmHg, RR of 16, HR 98 bpm and oxygen saturation of 89% on room air. Due to acute vision loss, a stroke alert was initiated. A head CT scan showed subcortical hypodensities in the bilateral occipital lobes consistent with PRES. He was started on Nicardipine drip in the ICU with subsequent decrease in blood pressure to 166/105 mmHg. His vision restored fully without further episodes of vision loss. Patient was found to be positive for COVID-19 and did not receive treatment for it as his shortness of breath and hypoxia resolved. The patient received maintenance hemodialysis, Nicardipine drip was weaned, and he was transitioned to oral blood pressure medications. Discussion: The relationship between kidney disease and PRES is not fully understood. Reported cases of PRES have been linked with hypertension, autoimmune disease, and immunosuppressive states, common diseases in ESKD. The pathophysiology of PRES appears to be related to cerebral blood flow dysregulation and endothelial cell dysfunction. The proinflammatory response in COVID-19 produces dysfunction and death of endothelial cells which may increase vascular permeability, promoting the cerebral edema seen in PRES. The estimated prevalence of PRES in COVID-19 patients is between 1-4%. Reports of PRES in ESKD are rare. PRES may not be readily recognized given the heterogeneity of presentation. Therefore, high index of suspicion is needed in the ESKD population.