Posterior reversible encephalopathy syndrome (PRES) attributed to mycophenolate mofetil during the management of SLE: a case report and review

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a rare clinical entity associated with systemic lupus erythematosus which characterized by seizure, headache, and altered mental status. The pathophysiology involves subcortical vasogenic edema secondary to hypertension and endothelial damage. PRES is reversible with withdrawal of the offending agent, strict blood pressure control, and treating the underlying disease. We report present here a patient with lupus nephritis who developed PRES following mycophenolate administration.

Keywords: Posterior reversible encephalopathy syndrome; adverse drug event; mycophenolate mofetil; systemic lupus erythematosus.

Figure 1

Echocardiography showed moderate mitral and three cusp regurgitation, mild aortic regurgitation, mild aortic valve regurgitation and left ventricular enlargement. echocardiogram-systolic pulmonary artery pressure (SPAP): 53 mmHg.

Figure 2

Renal biopsy: A: Diffuse proliferation of mesangial cells, mesangial matrix and endothelial cells, diffuse thickening of the basement membrane of the capillary wall, and electron dense deposits in the subepithelial, subendothelial, and mesangial regions (EM ×5000 magnification). B: Diffuse mesangial proliferative glomerulonephritis, diffuse mesenterium matrix hyperplasy, endotheliocyte hyperplasia. The diffuse thicked glomerular capillary walls, showing double track changes and narrowing of the lumen (H&E ×400 magnification). C: A large amount deposition of fuchsinophilic protein and the structure of “platinum ear” under the capillary endothelium (Masson ×200 magnification). D: Diffuse proliferative in the mesangial regions (Periodic acid-silver metheramine stain ×320 magnification).

Figure 3

(A) T2 weighted: T2-weighted sequences involving the cortical and subcortical regions of parietooccipital lobes. (B) ADC map showed an increase of the apparent diffusion coefficient (ADC) value, suggestive of vasogenic edema in the same regions. (C) Diffuse weighted image (DWI). (D) Fluid-attenuated inversion recovery magnetic resonance imaging (FLAIR) MRI image. Brain MRI image of the patient showed high intensity involving the cortical and subcortical regions of the parietooccipital lobes in T2 weighted, DWI, and FLAIR (A, C, D).

Figure 4

Brain magnetic resonance image 12 days after discontinuing Mycophenolate. Complete resolution of high signal intensities is shown compared with Figure 3.