Posterior reversible encephalopathy syndrome presenting as papilledema

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a central nervous system pathology characterized by headaches, altered mental status, seizures, and visual loss. The syndrome is a clincoradiologic diagnosis, which mandates neuroimaging. The aim of this study is to describe a case of asymptomatic PRES in which the only sign was incidental papilledema found on ophthalmologic examination. A thin 19-year-old female G1P1 s/p natural spontaneous vaginal delivery was referred to our emergency department (ED) by the ophthalmology clinic after finding bilateral papilledema on fundoscopic examination. She denied any fevers, chills, nausea, vomiting, as well as headache, lightheadedness, visual changes, or blurriness. Lumbar puncture was performed, and opening pressure was found to be greater than 55 cmH2O. After collecting Cerebrospinal fluid (CSF) for routine analysis, approximately 15 to 20 mL of CSF was drained. After several revisits to the ED, the neurology clinic was consulted. The magnetic resonance imaging ordered by the neurology clinic, as read by the radiologist, showed a focal lesion in splenium of the corpus callosum and diffusion restriction suggestive of acute infarction (although the anatomical location and age would be unusual). This is an atypical manifestation of PRES. The myriad of clinical symptoms and presentations of PRES has become more identifiable as more case reports of the syndrome are published. This case demonstrates that this atypical syndrome may present in an atypical way. The patient may be asymptomatic, and although imaging defines the diagnosis, a complete physical examination must not be ignored because the only sign may be papilledema.